District Nurses mismanagement of pressure sore leads to death of disabled patient

Mrs R was a mother of 3 in her early 50s and suffering from Multiple Sclerosis when she developed a pressure sore to her sacrum.  This was identified during an admission to hospital.  When she was fit to be discharged arrangements were made for the community nursing team to manage the sore.

Despite identifying the sore as grade 3 and noting that an air mattress was needed, this was not then ordered for a further 30 days.  Over the next few weeks it was clear that the wound was deteriorating and becoming necrotic.  A Tissue Viability Nurse (TVN) was eventually asked to see Mrs R and she prescribed good treatment which would soften and debride the wound and kill and protect against bacteria however this advice was not followed and instead a dressing was applied which would not alter the wound status.

The wound continued to worsen and became inflamed and the TVN recommended hospital admission as it was suspected that she was becoming septic.  Mrs R was treated with intravenous antibiotics but her pressure sore was now described as grade 4 and so she was discharged from hospital with a Topical Negative Pressure (TNP) dressing however the district nursing team were unable to manage the TNP and it transpired that it had not actually been working since she was discharged from hospital.

Over the next few days Mrs R looked increasing unwell.  She was losing weight and was suffering nausea and her family were struggling to cope with the dressing of the wound and caring for her.  The community nurses continued to visit but the record keeping became sparse and less detailed.  Mrs R continued to decline until she was admitted to hospital after being found unresponsive.  On admission, bone was seen to be clearly visible through the wound to her sacrum.  She was severely septic and no treatment could be offered.  She sadly passed away shortly after, only 5 months after the sore was first noticed.  It was concluded that the most likely source of the infection was her pressure sore.

We were approached by Mrs R’s husband and sons to investigate the standard of care their wife and mother had received and the independent expert reports we obtained were damning of the standard of nursing case given to Mrs R.  In particular, the independent nursing experts was of the view that they had failed to:

  1.        Arrange for pressure relieving equipment soon enough
  2.        Arrange for a TVN visit soon enough
  3.        Follow the TVN’s advice and the Trust’s own policy for managing pressure wounds
  4.        Manage dressings appropriately
  5.        Arrange for further review/earlier re-admission to hospital

With proper treatment the view was that Mrs R’s sore would have healed and a second medical expert agreed that the failures in her treatment and care resulted in her death from sepsis.

When these allegations were put to the Trust responsible for the community/district nurses, we were faced with denials and the Trust were very keen to push the burden and the blame on Mrs R and her family.

As a result court proceedings were commenced but shortly after solicitors acting for the Trust entered into negotiations to settle the claim and Mr R agreed to accept a five figure sum.

This was a terribly sad case.  Mrs R and her family had been dogged by her ill health for years but they had rallied.  For her to be failed so absolutely when she desperately needed help most devastated them.

Pressure sores require careful and intensive treatment.  They don’t resolve on their own and as this case shows they can prove to be fatal.  If you or someone you know has suffered a pressure sore or deterioration of a sore due to poor medical care and treatment, please contact us for a free discussion.

Ashleigh Holt – October 2018