Vet died from bed sores that had ‘rotted flesh to the bone’

AN INQUIRY into the death of a retired vet who developed an infected bed sore when she was living in a care home has heard that health professionals looking after elderly patients should improve the way they share information.

Jamesina MacKenzie, 87, a resident at Wyvis House in Dingwall when she fell ill and was taken to hospital. Doctors discovered she had a bed sore so severe that it had rotted the flesh down to the bone. Miss MacKenzie later died in hospital.

Yesterday, at the fatal accident inquiry into her death, procurator fiscal, Alistair MacDonald, told Sheriff Alastair MacFadyen:

“A reasonable precaution would be that communication should be improved.”

He told Dingwall Sheriff Court that this should involve all the health professionals in care for the elderly, including the care home, GPs, medical centres and hospitals.

The fiscal also recommended “improved record-keeping” at care homes in light of Miss MacKenzie’s death. The former veterinary surgeon was admitted to hospital after falling ill at the Wyvis House Care Home in Dingwall, Ross-shire.

A doctor who examined Miss Mackenzie at the County Hospital in Invergordon alerted police after he became concerned by her condition. She died shortly afterwards on 31 May 31, 2009.

Investigations were carried out at the home by Northern Constabulary, while staff from the Care Commission also inspected the premises following the death.

The inquiry heard evidence that the care home had an embargo on admissions placed on it following complaints – and just prior to Miss MacKenzie dying. There was also low staff morale and concerns of overworked employees at the care home, the court was told.

Rosemary Starr, 60, a retired Care Commission officer, carried out unannounced inspections just prior to the death.

Mrs Starr said she carried out inspections following the purchase of the care home by RDS Healthcare.

She said a quality statement prior to the purchase in January 2009 had found “staff morale was generally low’” employees were “often tired” and the home was “not adequately staffed”. After an unannounced visit in April 2009 she said many of the concerns were still there following the takeover.

She said the visit had come after a complaint, which was upheld, from a relative, adding: “It was to do with the length of time for staff to respond to buzzers. There was an embargo on new admissions on advice from the Care Commission. It was an unusual step to take.

“There were concerns about morale of staff and the level of anxiety at the care home. People felt anxious about the level of care.”

Mrs Starr said the embargo was instigated to “make a strong point to the providers about our levels of concerns about what was happening”.

She added: “The concerns were the similar to January, that employees were overworked and it was understaffed.”

The inquiry had previously heard from Dr Rosyln Rankin who said the cause of death was infection from pressure sores.

The consultant pathologist at Raigmore Hospital in Inverness Dr Rosyln Rankin said: “If her sores had been treated earlier, this lady could have lived for many more years. They are caused by prolonged pressure on bony parts of the body incurred from lying in bed, restricting the blood flow and causing decay. They are avoidable.”

Dr Rankin went on to tell the FAI: “One ulcer had gone through to the bone and you could see the femoral cap.

“We were told her pressure sores were some of the worst the staff had ever seen. When this wound was being dressed, you would have been able to see the hip joint working.”

The inquiry will continue on Monday.