Significant failings at care home ‘may have shortened mother’s life’

An investigation into a County Derry care home found that a patient's dentures were lodged in her throat for 24 hours before being detected. 

A report by the Northern Ireland Public Services Ombudsman found ‘significant failings’ in the resident’s care at The Cottage Care Home in Coleraine.

The resident also suffered a fractured leg when 'not enough care' was taken by staff when moving her from her bed to a chair. 

While moving the resident her foot became caught in the bedrail. Despite indicating she was in pain the staff continued with the move.

In the report the Ombudsman sought independent professional advice from a Registered Nurse (IPA) on what extent the fracture may have had on the shortening of her life. 

The IPA said the plan of care agreed with the family following the incident could have shortened her life as she remained in bed rest with regular pain relief, requiring frequent checks and positioning changes by nursing and care staff.

“It is entirely possible that [the Moving and Handling Incident] which resulted in a femur fracture, a leg cast, a need for frequent pain relief and a period of enforced bed rest and its accompanying negative side-effects could well have led to the shortening of [the Resident’s] life,” said the IPA with 17 years' clinical experience of nursing in the NHS.

“As well as being interrupted every two hours for these checks and repositioning, staff would also visit [the Resident] every half hour during the day and every hour at night to check to assess if she was in pain and [the Resident] would be given pain relieving medication regularly.

“Sleep disruption in care homes is known to increase the likelihood of early death in long-term residents and it is possible that the frequent checks and repositioning [the Resident] was exposed to could have shortened her life.”

The IPA said remaining in bed for a number of weeks can be detrimental for older people who are already frail. 

While the woman was on the chair the staff checked for injury but did not do it properly. The fracture went unidentified for a full day. 

The report found the home's failings in the care and treatment of the resident were preventable, and that the incidents may well have contributed to the shortening of her life.

Not enough care was taken while the resident was being helped to move from her bed to her chair according to the investigation. 

The Ombudsman credited dentures going unnoticed by staff to the lack of an oral health care plan and no clear oral health care policy The report said staff should have been quicker to recognise the possibility that the resident's breathing difficulties could have been due to her dentures going missing.

However it also found an 'appropriate moving and handling risk assessment' was in place during the moving and handling i n c id e nt . It also found that following the two incidents the home acted appropriately in its implementation of adult safeguarding procedures.

The resident's daughter complained to the Ombudsman about the incident.

Conway Group Healthcare, which owns the home, apologised to the woman's family. Ombudsman Margaret Kelly said it was clear that the resident's daughter and sons were devoted to their mother and very much involved in decisions regarding her care.

"The trauma and distress of losing her in the circumstances reflected in this report was evident in their correspondence to the home and to my office,” she said . 

“I understand that this report will have made distressing reading and I recognise the emotional impact on a family in bringing a complaint of this nature forward. 

"It is a testament to the love and devotion they had for their mother that they want to ensure no other family suffers a similar experience." 

As well as recommending the apology, the Ombudsman also asked the home to carry out staff training and service improvements in oral hygiene, and in the moving and handling of elderly residents . Its recommendations were accepted by Conway Group Healthcare.