Learning from Experience Database - Serious Case Reviews

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A and B (Kent)

Case 1 involved Mr A an older man with a history of Parkinson’s Disease who, after receiving respite care several time was admitted to a care home. At the time of admission he had no skin care problems but he was unfortunately injured as result of being left sitting next to an unguarded radiator that was faulty and dangerously hot. He was taken to the A&E Department and later saw a District Nurse who assessed him as having a high risk of developing pressure sores. There were delays in ordering pressure relieving equipment, collecting special dressings that were prescribed or seeking expert advice. He was then transferred to another home but the hand-over was not well coordinated and DN records were not transferred with him, so that his wounds continued to trouble him and he became emaciated and unwell: the pressure sore that had previously developed worsened. As he became more unwell and dehydrated; he either refused or was not administered his medication for Parkinsons, record-keeping was patchy and he was eventually admitted to hospital in a very poorly state six weeks later by which time his pressure sore was assessed as having reached grade 4. The second case concerned Mrs B an older woman, living in a care home who had dementia and towards the end of her life became bed-bound. She also developed pressure sores that became infected, received inadequate pain relief and suffered unnecessarily. Her situation was of particular concern as lessons should have been learned by the home after the death of the first client just 8 months previously. An anonymous whistle-blower sent letters and photographs suggesting that the quality of care at one of the care homes was below standard. The safeguarding alert, raised by the District General Hospital at the time of the first admission, led to the contract being suspended by Kent County Council and placements were stopped for a period of 3 months. The quality of care in were summed up in the following terms: “Serious failings were found. There was no wound assessment or evaluation. Records of dressings were intermittent and inconsistent. Documentation was generally poor with little evidence of what care had been given. Fluid balance charts were kept (though poor) but these were not acted upon”.

Professional learning:

  • Contracts should emphasise the requirement for staff to have the right skills to provide care including adequate written and spoken English.
  • Staff from BME communities should be supported to develop skills and helped to access information about particular conditions alongside other members of the staff team.
  • Anonymous information should be treated as intelligence and investigated or followed up without exposing whistleblowers or allowing others to cover up serious failings.
  • A post incident action plan should be agreed for services identified as having significant deficits setting out the improvements required and timescales.
  • Contracts and commissioning activity should support the safeguarding process for example, by implementing contract compliance and defaults measures and sanctions.
  • In such circumstances, NHS investigations should be undertaken under the auspices of the LSAB’s Safeguarding Process.
  • If a vulnerable adult who has been the subject of a safeguarding alert dies in hospital, a Police report should always be considered to explore whether neglect or mistreatment contributed to their admission or to their death.

2009 April Serious Case Review regarding A and B (Kent)