Family Call For Lessons To Be Shared After Hospital Pressure Sore Death

Narrative Verdict Recorded At Inquest Into Man's Death


Lawyers acting for the family of a man who died in excruciating pain after his pressure sores became badly infected have demanded lessons learnt from the case be shared throughout the NHS after an inquest found a lack of knowledge from nursing staff  contributed to a man’s painful death.

District Nurse  Louise Norton, 32, from Thatcham, Berkshire, claims that her father suffered ’unnecessarily’ and ‘horrifically’ shortly before he passed away in June 2009 at The Royal Berkshire Hospital.

Her comments echo an NHS Serious Untoward Incident Report (October 2009) which highlighted staff shortages and equipment failures.

And it comes after Coroner Peter Bedford last week (Wednesday 18 May) recorded a narrative verdict into the death of 64-year-old Mervyn Elkington, from Newbury, Berkshire, at Reading Coroner’s Court, saying that staff missed opportunities to treat Mervyn’s wounds properly and alleviate his suffering in the three months prior to his death when he was left writhing in agony.

Medical law expert Peter Cutler from Irwin Mitchell, who is now supporting the family in their battle for justice, said: “Although I welcome the changes the Trust has implemented since Mervyn’s death - following a thorough investigation they have reduced pressure sore occurrence across the Trust by 50 per cent by implementing new procedures - the treatment Mervyn received during his time in hospital was poor.

“The family now want assurances that lessons this Trust has learned will be shared nationwide to prevent the future, needless suffering of any other patients.”

He continues: “Though he was a very ill man when he was admitted to hospital, the inquest into Mervyn’s death has revealed a series of severe failings that led to him suffering extreme pain for months leading up to his death.”

A catalogue of failings outlined by the coroner at the inquest included:

  • A series of missed opportunities to treat the source of Mervyn’s pressure sore infection including delays in arranging MRI scans and delays in arranging appropriate surgery to treat the infection
  • If the surgery Mervyn had to endure toward the end of his life to remove rotten flesh had been performed two months earlier he may not have gone into septic shock after the procedure which ultimately led to his death
  • A lack of familiarity among nursing staff on how to operate electronic  beds and mattresses designed to keeps patients mobile and alleviate risk of pressure sores becoming infected
  • Medical notes not correctly kept including weight charts, wound assessment chats and repositioning charts
    The opinion of a tissue viability nurse -who would have established an appropriate care plan to treat Mervyn’s pressure sores - should have been sought earlier
  • Although it was acknowledged that the extensive nature of Mervyn’s pressure sore damage was unusual, not all staff knew how to treat the condition despite receiving guidance from specialists
  • The high number of agency staff affected the continuity of Mervyn’s care

Admitted to hospital in March 2009 suffering from chronic renal failure, the grandfather of five’s health continued to deteriorate as he continued to suffer painful and infected pressure sores. Having spent months in agony, medical staff finally realised the extent of the problem and attempted surgery to remove rotten flesh caused by infected pressure sores, but by then it was too late as Mervyn’s body was in such distress that he went into septic shock and tragically died on 19 June 2009.

Commenting on her family’s tragic loss, Mervyn’s daughter Louise said: “My father was a loving, caring man and we miss him every day. Towards the end of his life he was extremely unwell and put his health in the hands of medical staff, trusting them to do everything possible to help him and make sure he was comfortable. But instead he died in excruciating pain. To know that more could, and should have been done to prevent his suffering is simply unbearable.

Louise continued: “It is too late for my father. He died in such unnecessary pain and it was horrific to watch. I wouldn’t wish that on anybody so if by speaking out we can, somehow, force change I will feel that in some small way justice has been done.”