A great-grandmother suffered agonising pain for the final year of her life as district nurses failed to properly treat a bedsore, allowing it to develop into a “weeping black hole” in her lower back.
The 84-year-old woman, who had Alzheimer’s disease and had been through throat cancer, was bedbound by her frail health and lived with her family at their home in Lambeth.
Now the trust in charge of her care, Guy’s and St Thomas’ NHS Foundation Trust, has agreed it did not look after her well enough and paid her family £25,000 in damages.
The pensioner had developed a small bedsore at her family home, so they called their GP who arranged for district nurses to visit three times a week. Nurses reduced the visits to just one day a week – and she developed a second sore where dressings had been removed from the initial wound by nursing teams. They then failed to treat the new wound properly.
Her family raised concerns over her worsening conditions, but claimed they were dismissed by the district nurses.
But a subsequent examination revealed the second sore had become so bad it was considered to be grade three or four – the most severe – where skin is severely damaged, and underlying muscles or bone are in danger of being affected. Around 90 per cent of the woman’s skin in the area of the sores had become “necrotic” – or so badly damaged that the cells had effectively died.
It led to the district nurses, employed by Guy’s and St Thomas’ NHS Foundation Trust, (GSTT) being instructed to visit daily again and the elderly woman being admitted to hospital because of an infection.
The woman required ongoing care from her family after her discharge from the wards, as well as another set of district nurses, until she died 10 months later, on April 4, 2014, aged 85. The woman’s daughter, who has asked not to be named, said she could not believe how the problem had been allowed to escalate from a small initial sore, when they first sought medical support.
“Mum developed a really small sore, which looked like a graze and I was told that I should call the doctor at the first sign of anything like that, so I did,” she said.
“Mum’s skin was paper thin. When the initial mark had gone, the dressings the nurses were using were too sticky and caused the second sore. I kept asking what it was and they said it was nothing.
“But then it went black and ended as a weeping black hole.
“When mum was in hospital, they had to cut the black area away. I put in a complaint to social services and had meetings with them, as well as the Patient Advice and Liaison Service (PALS) and safeguarding. I went to meeting after meeting.
“Mum had a specialist chair at home, but by the time she came out of hospital the sore was so bad that even the nurse was frightened to get her out of bed.
“She was completely bedbound and in pain, but with her having Alzheimer’s, she couldn’t communicate how bad it was.
“She previously had throat cancer and had a tracheotomy, so she’d already been through so much, so to watch her deteriorate in front of our eyes was heartbreaking.
“The treatment my mum received was disgraceful. We did everything for mum and that was our choice as a family. But we didn’t want her to suffer on top. You should be able to believe and trust what a nurse says.
“When mum died her death was put down to pneumonia, but I also believe the sore didn’t help because it never got any better, it only got worse.
“Mum was a brilliant person and we were so close. She brought seven of us up on her own and worked hard all her life. She didn’t owe anyone a bean and she was a warden for people living in sheltered housing, so she really cared for other people.
“She was a very respectable woman and I wanted her to have dignity and respect in her later years. But what happened to her was completely degrading.
“I don’t want anyone else to have to go through this. My mum went through this with a big family. What about the people who don’t have anybody? There are lots of people who don’t have any family or support.” Guys’ and St Thomas’ NHS Foundation Trust admitted the nursing care fell below the standard to be reasonably expected and agreed to paying the woman’s family £25,000 in damages, following legal action, through medical compensation specialists Hudgell Solicitors.
The trust also admitted the patient had not been assessed properly for the affliction, nor was she placed on an appropriate mattress despite being at a high risk of developing sores having had several additional health problems.
It also admitted that, as a result of the inadequate care and the sores deteriorating into a grade three or borderline grade four, she developed an infection for which she was admitted to hospital and suffered prolonged pain and suffering for 12 months.
Kirsty Yates, of Hudgell Solicitors, represented the family throughout the case and said it was a clear case of inadequate care.
She said: “The last 12 months of this lady’s life were spent in a lot of pain and discomfort, which was terrible for her and her loving family who cared for her and loved her.
“Her family could only do so much and they put their faith in the trust and the nurses, but they failed to provide the care expected.
“As she was elderly and bedbound, she was at high risk of pressure sores anyway, so it was completely inexcusable not to conduct pressure ulcer risk assessments and make appropriate plans for treatment.
“Research suggests 95 per cent of pressure sores can be avoided by providing appropriate bedding, and making sure patients move and, if necessary, are turned regularly. This shows situations like this should be avoided.
“The fact that the second sore then developed, and was allowed to deteriorate to the extent that it did, was shocking.”
The woman’s daughter added: “When I turned to Hudgell Solicitors, it was the same month my mum passed away and I wanted to take it further to get my point across about how she was treated. I wanted them to be held to account. Kirsty did that superbly and was always there when needed.”
A spokesman for GSTT said: “We are very sorry that in this case the nursing care fell below the high standards we set for ourselves and our patients. Since this case three years ago we have put new training programmes in place to help staff recognise and treat pressure ulcers more effectively.”