'Beryl', 82

Beryl was a resident at a care home and whilst a resident was assessed as being at very high risk of developing pressure sores. Advice was given for her to be placed on a pressure relieving mattress, checked thoroughly due to her double incontinence and that any sign of pressure ulcer should be reported to the nurse, for referral to the tissue viability nurse.

Unfortunately, Beryl developed a pressure sore in her sacrum and she became unwell, requiring hospital admission for antibiotics to treat the sacral sore, which had become infected. The abscess successfully healed, although there was a red area in the sacral area which was treated with barrier cream. Beryl was eventually discharged back to the care home two weeks after being admitted to hospital.

More pressure sores developed

Advice was given at the care home for Beryl to be placed on a pressure relieving mattress, to be checked and washed regularly and, if a pressure ulcer developed, to advise the nurse of the situation, who would then refer the patient to the tissue viability nurse.

Beryl developed a further pressure sore over the next month and was reviewed by her GP, who prescribed antibiotics. Her GP also noted that two further pressure sores had developed in Beryl’s sacrum and back.

Failure to refer to tissue viability nurse

The pressure sores deteriorated, one of which grew to measure 5cm x 5cm. No further action was taken until the following month, when Beryl’s GP came to visit her and advised that she be referred to the tissue viability team. Unfortunately, this referral was not actioned and the pressure sore developed further into a 6cm x 6cm, Grade 4 sore. She was admitted to hospital and unfortunately passed away six weeks later due to sepsis, caused by a chest infection and a sacral pressure sore.

Inquest into Beryl's death

The matter was referred to an inquest, where the Coroner ruled that the cause of death was linked to the pressure sore and Beryl would unlikely have died when she did had there not been omissions in the nursing care provided. Criticisms were raised at the inquest of the failure to refer Beryl to the tissue viability nurse prior to her hospital admission.

Settlement

The case was settled by one of JMW’s expert solicitors for £25,000.