A daughter traumatised by the substandard care her elderly mother received and which ultimately contributed to her death whilst in hospital, agreed to a four-figure compensation settlement with The Leeds Teaching Hospitals NHS Trust.
Doris Paver was admitted to St James's University Hospital and died two months later. The case, handled by Medical Negligence Solicitors at national law firm Simpson Millar, shed light on the appalling treatment Doris experienced which caused considerable distress to her and her daughter Valerie King.
"As a result of the Hospital Trust's negligent care Mrs Paver developed a Grade 4 pressure ulcer and 6 other minor pressure ulcers; underwent an unnecessary invasive surgical procedure which then materially contributed to her death. She suffered throughout with poorly controlled pain, a dry mouth and was left in soiled bedding with little respect of her dignity", says the Medical Negligence Solicitor who handled the compensation claim.
"It is stressful enough dealing with the emotional strain of a sick mother, without the added worry about her physical wellbeing, a lack of adequate pain management and a loss of dignity for the duration of her stay," adds Val. "It was clear to me from the outset that Mum was not getting the proactive support she desperately needed from the nursing and medical teams."
Following her husband's diagnosis of terminal cancer Doris was unable to cope and sadly she had a breakdown. Whilst receiving treatment under the care of Leeds Mental Health Trust she was diagnosed with Parkinson's disease which came on very quickly.
"Mum moved in with me and my husband but her cognition deteriorated and it became clear she required specialist nursing care to help with her increasing confusion. Shortly after moving in to the Pennington Court Nursing Home in Hunslet, she was admitted to St James's University Hospital as she had been found unresponsive during the previous evening," recalls Val.
When admitted to hospital, Doris was recorded as having a grade 1, (red skin but unbroken) pressure ulcer, on her sacrum, however due to the Hospital Trust's admitted failure to provide appropriate pressure care this deteriorated to a grade 4 pressure ulcer which meant that there was full thickness tissue loss with Doris' coccyx bone exposed.
Doris also went on to develop six further grade 1 ulcers to each heel and buttocks and a two further to her sacral area. However, the Trust disputed the accuracy of their own records and contended that Doris already had a grade 3 ulcer on admission and the deterioration of this ulcer could not have been avoided, despite her having just recovered from minor ulcers under the care of the community nursing team when at the nursing home.
"In some ways we were relieved as we believed the hospital would be better equipped to meet her care needs. It was a terrible shock to discover this was not the case, and as things turned out the lack of care she received contributed to her discomfort and death,"
Despite having been assessed as being at a very high risk of developing pressure ulcers Doris was initially left on a narrow hospital trolley in A&E for five hours without a suitable mattress before a bed was found which increased the development of pressure sores, and did not facilitate turning.
"She was supposed to be turned hourly but for the duration of her stay this did not happen," says Val. "She also needed a special mattress that reduces pressure but there was a delay of a few days before this was provided. Seeing her prolonged suffering was dreadful, she was often in pain which was not managed, and I was constantly at my wits end."
Doris should have had a 'Turn Chart' in place but there was no such documentation in the records. It was therefore impossible for staff coming on and off different shifts and working during a busy shift to determine on which side/position and at what time Doris should be moved to next and when without this record.
Also, it would not have been possible for the Registered Nurses to determine that this care had taken place on a regular basis without this form being completed and signed by the relevant staff.
"I would visit for three to four hours at a time and not once during would my mother be turned," said Val.
Due to her medication, poor swallow and Catatonic Depression Doris had symptoms of thirst (and associated dried mouth) and nausea. She was also mouth breathing which exacerbates dryness. She was unable to look after her own mouth hygiene and was reliant on the nursing staff. Daily entries in hospital records showed that on occasion Doris refused mouth care.
Under such circumstances staff it is up to the staff to look at ways in which compliance with such care could be encouraged and to continue to try to administer mouth care in one way or another. There was no evidence this was done or that a care plan was in place to direct how this should be done.
"I used up to 10 mouth swabs to clean out matter from around her gums and remove brown skin from her lips during each visit, and it was obvious staff ignored her mouth care needs, including moisture and teeth cleaning. At the slightest sign of resistance, they just gave up. She was very vulnerable and needed more time, explanation and encouragement in order to accept care. If I could do it why couldn't they?" says Val.
"Mum had problems with swallowing and I understand that poor nutrition is a compounding factor in relation to pressure area care. However, when her swallow was good enough to take food and fluids, because of the state of her mouth I am concerned that she would not have been inclined to do so, therefore reducing further her nutritional intake."
A Medical Negligence Solicitor at Simpson Millar added, "Pressure ulcers (often referred to as bed sores and pressure sores) are painful and debilitating to those who are unfortunate enough to suffer them. If they are not identified and treated early, they can go on to deteriorate quickly to levels that can leave a cavity exposing the muscle and, in the worst cases, exposing the bone as was the case with Mrs Paver."
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"The vast majority of pressure ulcers are preventable," they continue, "and the financial cost of not dealing with them is far higher than the cost of taking action to prevent or reduce the number of pressure ulcers.
The cost to the NHS of treating pressure ulcers and related conditions is up to £4 billion a year, with the most severe cases ranging from £11,000 to £40,000 per person. Patients should not have to endure the pain and suffering related to pressure ulcers and the emphasis is now on the Hospital Trust to prove how they have learned from the admitted failings in Mrs Paver's pressure management care.
"When a patient cannot give consent to a medical procedure because they do not have capacity the final decision rests with the clinicians. However, this does not mean that they need not involve those close relatives, friends or others who take an interest in the patient's welfare. The Mental Health Act 2005 requires doctors to do so where it is practical and appropriate." says our solicitor.
"This is a very sad case and the family hope that as a result of bringing these issues to the fore the Hospital Trust will offer training and reassurance that there will not be a recurrence of such disturbingly inadequate hospital care."
In substantiating the complaint of poor mouth care, the Leeds Safeguarding Adults Partnership reported following their investigation that was initiated in June 2011 that "no specific care plan was in use, the care plan used was insufficient…artificial saliva took 3 days from ordering to be delivered…(Doris) required greater care but nursing staff were not always available and the Trust should introduce mouth care as standard."
Notwithstanding the substantiated complaint of inadequate mouth care the Hospital Trust denied the allegation. Undeterred and unconvinced by the denial Simpson Millar fought on and subsequently the Trust conceded that some aspects of Doris' oral care was negligent.
"When I went to go and see Mum she was in pain many times and was crying out, she said the pain was wicked" recalls Val. The Safeguarding report recorded that the Trust's staffing levels fell short of the agreed levels. The Hospital Trust admitted that Doris' pain management was substandard.
Doris also suffered the indignity of being left semi naked in an open ward, and toileting was neglected resulting in several occasions when Val and several other visitors found her undressed in a soiled bed. There were no specific care plans to address how the staff would manage either her continence needs or her dignity. There was no specific care plan in place or entries in the daily evaluation sheets that indicated that the staff had any consideration for Doris' dignity and how they could ensure as far as practically possible that the staff addressed this issue.
In relation to her continence needs there was no specific care plan to indicate how the staff would manage this. Doris was already using pads on admission but the hospital staff on the ward did not continue to use these. It was not until much later did they insert a catheter.
"I acknowledge that it would have been a challenge for the staff to maintain Mum's dignity at all times however, given the lack of detail in the care planning it suggests to me that the staff did not consider this aspect of her care significant," says Val. "When I visited my Mother, there were often no pads in place and she was naked and on view, sometimes with male visitors present in the area."
The safeguarding report substantiated the complaint of lack of dignity and recorded that on one of the occasions staff were present to address the situation but failed to do so. The Trust admitted they failed to protect Doris' dignity but denied they failed to provide adequate toileting care. Again, following further submissions from Simpson Millar the Trust conceded that there was no appropriate care plan in place to manage Doris' toileting needs.
As Doris was starting to take food orally the Trust proceeded with an invasive procedure to surgically fit a PEG (Percutaneous Entero Feeding Tube) so as to be able to give nutrition direct through a tube into her stomach. However, it was alleged that the Hospital Trust failed to involve Doris' family in the decision making process, (as they are obliged to do) and neither was the procedure in her bests interests.
"One of the worst things was finding she had been given a PEG through her stomach without our knowledge or consent, rather than 'comfort feeding' as and when she wanted it. It was only through finding leaflets regarding PEG feeding in mum's cubicle following the surgery that I became aware that she had had it done." explains Val. "Mum suffered a complication during the PEG procedure which was suspected to be either a gastric leak or perforation of her large intestine which resulted in fluid leaking around the PEG site causing painful bile burns around her tummy."
The safeguarding report substantiated the failure by the Trust to obtain consent for the PEG and noted that the form completed by a junior doctor was not countersigned by senior medical staff. Neither was it signed by Val.
Doris sadly died on 1 May 2011 and the certified cause of death was bronchopneumonia due to intra-abdominal sepsis. It was alleged that the PEG materially contributed to Doris' death. The Hospital Trust denied it failed to obtain valid consent, that PEG feeding was inappropriate or that it contributed to Doris' death.
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