Pressure Sore Treatment Lacked Urgency at St Peter’s Hospital

An inquest into the untimely death of an elderly grandmother at St. Peter’s Hospital in Chertsey has heard from a senior physician at another hospital that the treatment plan which may have prevented her death “lacked urgency”.

The 87 year old lady died on 1st July last year (2016) from sepsis which was due to an untreated pressure sore on her sacrum. She had originally been admitted to the hospital because of weight loss and diarrhoea concerns a month previously.

The assistant coroner at the inquest, concluded in her summary that although pressures sores are “natural”, neglect at the hospital had contributed to her death.

An East Surrey Hospital consultant, said that the fact that an intravenous feeding plan was never put in place may have contributed to the worsening of the ulcer as she was not eating anything else except for “a few spoonfuls.”

In addition to the lack of suitable nutrition, a note to the tissue viability nurse (TVN) about the condition of the ulcer was disregarded until a week after the note had been made. When the TVN eventually checked it was observed that the hospital’s normal policy to deal with pressure sores had not been put in place.

The policy would normally have ensured that the patient was physically turned regularly on her bed and daily skin checks should have been carried out.

The “lack of urgency” related to the fact that, treatments may have been carried out eventually but not initiated when they should have been. “When something needs to be done, it needs to be done as soon as possible,”

The family said that they thought that the verdict at the inquest was a fair one and they were glad that the hospital “could not cover anything up”. She expressed some frustration that whenever she had asked some of the staff at the hospital about her mother, that nothing had been done.

The assistant coroner recognised that the hospital had made significant changes to the way they dealt with pressure sores since the death, but was still going to produce a “Prevention of Deaths” report as she had concerns about the circumstances that led to the death.

Apparently there were a combination of factors that were to blame. These included:

• lack of action on the nutrition plan;
• doctors remaining unaware of the existence of the pressure sore until too late;
• agency staff at the hospital not being briefed about the hospital’s normal procedures;
• understaffing at the NHS hospital.

The Ashford and St. Peter’s Hospital’s NHS Foundation Trust has issued an apology to the family and has promised to improve all the concerns raised as a result of the death.

In this day and age there is simply no excuse for a “lack of urgency” when dealing with pressure sores. Pressure sores are not difficult to diagnose and their prevention and treatment is well understood. If pressure sores are allowed to develop into a dangerous condition, then this is due to negligence, not lack of medical knowledge.

If you have an elderly relative in a residential nursing home or hospital and are concerned about the way he or she is being treated, you must bring it up as a matter of urgency with the management of the institution. If repeated attempts to get some action fail, talk to a solicitor, preferably one with experience in dealing with pressure sore personal injury claims, about your legal options. It is far more preferable to get satisfactory action before a pressure sore becomes a serious health risk than deal with a tragic result of negligence.