Too Late For Mrs Forrester – The Diary of a Welsh Pressure Sore Tragedy

An inquest into the death of a Rhos-on-Sea, Conwy, care home resident due to complications from pressure sore sepsis has concluded that the death was due to negligence at the home. Halewood Home is now closed, but the death last year of 80 year old Mrs. Forrester prompted concerns for the other residents at the home before it closed and before the two day inquest in Denbighshire was called.

The time line of the developing tragedy probably mirrors that of many other victims of pressure sore neglect so it is instructive to have a look back at what went wrong.

Examination of the home’s own records show that staff at the home had reported concern about the state of the sore on Gloria Forrester’s body 19 times before she was eventually taken to hospital. It appears that even when her final trip to Ysbyty Glan Clwyd Hospital took place, this was not due to anything that the home had initiated. It was due to a visit by Mrs. Forrester’s daughter, Sarah Williams, who noticed that her mother’s room had a strong odour in it. She called the community nurse who, on examination of the sore, took steps to send her to hospital. Unfortunately, it was too late. Gloria Forrester died after two weeks being cared for at the hospital from respiratory failure due to sepsis.

During the inquest, the home’s owner, Maureen Parry, and several of the staff were asked about Mrs. Forrester’s condition at the home and what they had observed about her developing pressure sore in particular.

There was a certain amount of contradiction between some of the ex-staff answers and that of Mrs. Parry. More than one worker at the home commented that they had noticed the sore developing and had told Mrs. Parry, but she didn’t appear to do anything about it. One of the workers, Olwen Jones, said that Mrs. Parry had told her that the sore “would improve”. Mrs. Jones said that as far as she was aware that there was no form of care plan available at the home that could be used to deal with pressure sores. Employees were reliant on letting the owner know what they noticed.

The coroner at the inquest, Nicola Jones, asked Ms Jones why she hadn’t contacted a nurse or doctor herself. Ms. Jones replied that Mrs Parry wouldn’t allow it. Other carers expressed surprise that Mrs. Forrester had died after removal from the home. Mrs. Parry said that if she had known that the sore had been that bad, she would have notified the nurse much sooner.

The inquest heard the results of an investigation into the death which took place after Mrs. Forrester’s death had highlighted problems at the home. The medical expertise of the home’s owner, record keeping, staff training, whether a needs assessment on entry to the home was carried out, availability of a care plan for staff and readiness to ask for medical help were all investigated by staff from Conwy County, police and the Health Board.

The investigation concluded that in every aspect, there was a deficiency. Mrs. Parry herself admitted that she had no medical training when she started the home, but had “learned a lot” during the 31 years running it.

One recommendation that may have avoided Mrs. Forrester’s condition worsening was that someone on each shift at the home should have had the authority to contact a nurse or doctor if they were concerned about deteriorating condition of any of the home’s residents. Investigators had been told that only Mrs. Parry was able to do that.

The inquest concluded that neglect at the hospital, including a reluctance to seek medical attention, contributed to Mrs. Forrester’s death.

If your elderly relative is being cared for at a private nursing home, it is important that you take a keen interest in the way the home is run. Ask whether employees have been trained to cope with medical problems like pressure sores and what their mitigation plan is if a sore is discovered. Discuss any concerns with the management or owners of the home and if unsatisfied with the response, talk to a solicitor about legal action you could take to help protect the welfare of your family member.