Nursing home investigated after man dies from septic shock
A south-east Queensland nursing home has been investigated by the state coroner after a 69-year-old man suffering from severe bed sores died of septic shock.
The Queensland Coroners Court heard the man who, who suffered from prostate cancer, hypertension and Parkinson’s disease, started living at the nursing home on August 24, 2012.
The report stated that within 31 days of living at the nursing home the man referred to as Mr RO’H, developed his first bed sore and within another 63 days two more wounds were identified.
A 69-year-old man who had been living in a nursing home died in 2013 from septic shock (file picture).
Photo: Nicolas WalkerThe overview of the nursing home records, provided within the report, showed the man was treated with antibiotics but the wounds continued to be “oozing”.
On February 15, 2013, it was noted the man had lost 5.7 kilograms in a week and on February 17 his temperature was recorded as 38.7 degrees.
Doctors were not called, and at a routine appointment with a general practitioner on February 22, it was suggested he be sent to a hospital.
The man was taken by ambulance to Logan Hospital on February 23, 2013.
The coroner’s report said he arrived at the Logan Hospital unresponsive and with low blood pressure and a fever.
He had five bed sores of varying severity with the wounds on his right buttock and right heel classified as stage 4 – the most severe stage, which can be so deep they expose tendons, muscle and bone.
The man died four days later with the cause of death found to be septic shock, due to or as a consequence of infected bedsores that were complicated by bone inflammation.
As part of the investigation, the coroner called on a forensic medical officer who reviewed the adequacy of care and treatment the nursing home provided to the man.
“The forensic medical officer observed the records were clearly incomplete and appeared to be a combination of handwritten and electronic notes," the report stated.
The officer expressed concern about the nursing care provided and the care of the bed sores, the assessment of the man’s dietary requirements, meals provided and the delay in transferring the man to the hospital once he became septic.
Royal Brisbane and Women’s Hospital complex wound management nurse Kerrie Coleman also provided an expert opinion and raised concerns about the nursing home’s compliance with national wound management guidelines.
The investigation's finding said Ms Coleman believed the nursing home failed to assess and put in place a pressure injury prevention plan within an acceptable period.
“Ms Coleman is of the view that the pressure injuries may have been prevented if the nursing home had following evidenced based guidelines and instituted initial risk assessment and regular re-assessment of risk and prevention plans,” the findings stated.
“In Ms Coleman’s opinion, nursing staff should have contacted the general practitioner and Mr RO’H’s next of kin on 16 February to arrange for his immediate transfer to hospital for review of his condition.”
Given the seriousness of the man’s condition when he was admitted to the hospital, and the concerns raised by the forensic medical officer, the coroner referred the case to the Office of Aged Care Quality and Compliance (OACQC) so they could consider if the care provided was adequate.
The coroner's findings reported that following the referral, the nursing home made many significant changes including appointing a clinical team leader, establishing a wound management team, additional staff training on wound care and management, nutrition and the importance of maintaining proper and detailed records and updating the nursing home’s hospital transfer policy.
“I share the concerns raised by the forensic medical officer and Ms Coleman in relation to the evident shortcomings in the care provided by the nursing home to Mr RO’H,” the coroner’s conclusion said.
“A lack of adherence to evidence-based guidelines and regular risk assessment and prevention plans clearly led to poor treatment and management of Mr RO’H’s bedsores.”
The coroner said since the death the nursing home had worked with OACQC to rectify the inadequacies identified.
“I am satisfied that, if following and enforced, the implemented measures by the nursing home will sufficiently address the concerns arising in relation to Mr RO’H’s death.
The coroner closed the case on September 20, 2017.
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