''Lessons must be learnt' after dementia patient's death at Southampton General Hospital

Daily Echo: ''Lessons must be learnt' after dementia patient Kathleen Littlejohn's death ''Lessons must be learnt' after dementia patient Kathleen Littlejohn's death

“LESSONS need to be learned”.

Those were the words of a coroner as he heard the level of care received by an elderly dementia patient in the run up to her death at Southampton General Hospital.

Grandmother Kathleen Littlejohn, 82, died at the hospital two weeks after arriving from The Gables Rest Home in Netley Abbey with a leg wound after suffering a series of falls.

The inquest heard how a catalogue of errors including failing to assess her for dementia, a breakdown in communication between medical staff and family, a delayed blood test and not ensuring she was eating and drinking enough, contributed to poor care before her death.

Daily Echo: Southampton General Hospital.

In a shocking case which could have groundbreaking repercussions for future elderly care, coroner Keith Wiseman demanded hospital bosses improve a raft of “systematic failings”.

Family members were forced to make her bed and ensure she was properly clothed at one point, the inquest was told.

The hospital has conducted a major report into the failings.

The inquest heard how the retired dinner lady arrived at the wards on October 5 of last year with a haematoma in her left leg which subsequently burst at hospital.

It became infected and she succumbed to sepsis and the diarrhoea and vomiting bug Clostridium Difficile (C Difficile) before dying on October 22.

Daily Echo: Coroner Keith Wiseman

Coroner Keith Wiseman

Her grandson Matthew Watts slammed staff for failing to set up a dementia care plan, sufficient pain management or bedrail assessment – meaning she subsequently fell from a bed while there.

He said: “If she had been assessed properly she would have been better understood - how did it slip through the net?”

He told the inquest a “critical path” in her condition was a delayed blood test.

The test was requested on October 18 but doctors were unable to find the results the day before her death and were forced to arrange another one.

He also said staff were failing to ensure she ate or drank enough and added: “Considering her fragility if someone’s not taking on nutrition and hydration and people don’t intervene, surely that plays a part in her deterioration?”

Daily Echo:

Kathleen Littlejohn

Her daughter Sandie said at one point she had to make her mother’s bed and put on some bed socks to keep her warm.

The family had been trying to contact doctors for eight days for an update on her condition and at one point a doctor took four hours to come to her bedside.

Hospital divisional director Dr Derek Sandeman insisted the infection was not critical in her death.

He was unable to tell the family why the blood test was delayed but suggested it could have been labelled with the wrong ward.

He agreed poor nutrition had been a “significant contribution” to her overall poor care but did not lead to her death.

He said: “She had so many critical issues.”

But he admitted communication had been a “central failing” and added: “Our apologies.

“The team took a while to understand the whole nature of the failings themselves.

“We have got to do a lot in the future to look at these failings.

“Some are systematic and some are individual but they are real and we have to look at it.”

Consultant physician Doctor Mark Baxter, pictured below, who was treating her also apologised for communication failings.

Daily Echo:

He said: “It is quite distressing for everybody and we do try our hardest.

“In this case the standard of communication is probably not where it should be.”

The inquest heard the cause of death was down to dementia, infected haematoma, sepsis and C Difficile.

Coroner Keith Wiseman stressed more had to be done to improve dementia care – especially to protect safety and ensure patients are properly fed and hydrated.

He told the court: “It’s self evident a patient needs to be eating and drinking properly.

“If not, it’s bound to be a detrimental factor, if not an adverse factor.”

Adjourning the hearing until April 17 for a verdict he said: “Not only were certain aspects of care suboptimal but communication with the family on key issues was bordering on the non-existent.

“I hope lessons will be learned and care improved because there’s going to be many hundreds and thousands of people not in a dissimilar situation.

“The hospital are conscious that they need to improve that.”

  • Additional reporting by Michael Carr

Comments (11)

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1:02pm Thu 27 Mar 14

espanuel says...

The same old answer, Lessons must be learnt / have been learnt the same old excuse. Doesn't anybody learn anything, isn't there a program laid out that if a patient comes into a ward that they do an assessment of that patient and leave it on file. So bloody easy.
The same old answer, Lessons must be learnt / have been learnt the same old excuse. Doesn't anybody learn anything, isn't there a program laid out that if a patient comes into a ward that they do an assessment of that patient and leave it on file. So bloody easy. espanuel
  • Score: 0

4:07pm Thu 27 Mar 14

cantthinkofone says...

Communication between doctors and nurses is poor nationwide. Too many doctors seem to feel they're far to busy and/or important to properly communicate with the ward staff that are providing the day-to-day care of their patient. It's an elephant in the room that needs to be urgently addressed by the Royal Colleges.
Communication between doctors and nurses is poor nationwide. Too many doctors seem to feel they're far to busy and/or important to properly communicate with the ward staff that are providing the day-to-day care of their patient. It's an elephant in the room that needs to be urgently addressed by the Royal Colleges. cantthinkofone
  • Score: -1

4:35pm Thu 27 Mar 14

nelson1 says...

cantthinkofone wrote:
Communication between doctors and nurses is poor nationwide. Too many doctors seem to feel they're far to busy and/or important to properly communicate with the ward staff that are providing the day-to-day care of their patient. It's an elephant in the room that needs to be urgently addressed by the Royal Colleges.
With espanuel also. 2 issues which would help if corrected.

1. Proper details recorded on admittance and posted at the end of each patients bed together with named hospital doctor allocated as lead physician - doctor details also noted on admission documents, including hospital telephone number and text/e-mail contact details.

2. Regular daily posted ward round times, so patients relations can dialogue with nominated doctor and share any additional information they feel is relevant. Senior ward nursing staff to attend each patients daily assessment/review so they can pass information onto their floor nurses.

Is this really too difficult to do?

Common sense is not common ?
[quote][p][bold]cantthinkofone[/bold] wrote: Communication between doctors and nurses is poor nationwide. Too many doctors seem to feel they're far to busy and/or important to properly communicate with the ward staff that are providing the day-to-day care of their patient. It's an elephant in the room that needs to be urgently addressed by the Royal Colleges.[/p][/quote]With espanuel also. 2 issues which would help if corrected. 1. Proper details recorded on admittance and posted at the end of each patients bed together with named hospital doctor allocated as lead physician - doctor details also noted on admission documents, including hospital telephone number and text/e-mail contact details. 2. Regular daily posted ward round times, so patients relations can dialogue with nominated doctor and share any additional information they feel is relevant. Senior ward nursing staff to attend each patients daily assessment/review so they can pass information onto their floor nurses. Is this really too difficult to do? Common sense is not common ? nelson1
  • Score: 3

6:02pm Thu 27 Mar 14

999medic says...

Whilst this is an horrific example of care, we must remember that the hospital treats tens of thousands of patients every year with out problems. There is no excuse for the this lady or her family to have suffered, but remember one thing junior drs come and go and it's the nurses who have to look after both them and the patient and staffing is appalling. I would challenge anyone not connected to health care to spend one week shadowing a mau nurse then see how difficult it gets.
Whilst this is an horrific example of care, we must remember that the hospital treats tens of thousands of patients every year with out problems. There is no excuse for the this lady or her family to have suffered, but remember one thing junior drs come and go and it's the nurses who have to look after both them and the patient and staffing is appalling. I would challenge anyone not connected to health care to spend one week shadowing a mau nurse then see how difficult it gets. 999medic
  • Score: 6

6:31pm Thu 27 Mar 14

Hiram Abiff says...

Every time someone is let down by social services we get ''Lessons must be learnt''.

So why don't they learn the lessons and stop making mistakes?
Every time someone is let down by social services we get ''Lessons must be learnt''. So why don't they learn the lessons and stop making mistakes? Hiram Abiff
  • Score: -2

6:45pm Thu 27 Mar 14

nelson1 says...

999medic wrote:
Whilst this is an horrific example of care, we must remember that the hospital treats tens of thousands of patients every year with out problems. There is no excuse for the this lady or her family to have suffered, but remember one thing junior drs come and go and it's the nurses who have to look after both them and the patient and staffing is appalling. I would challenge anyone not connected to health care to spend one week shadowing a mau nurse then see how difficult it gets.
Absolutely correct.
Nurses are being scorned for being late with medicine, and yet are holding their bladder because they do not have time to use the toilet, and starving because they missed lunch. They are being peed on, puked on, shat on, bled on, bitten, hit and yelled at and are missing their families while taking care of yours. They may even be crying inside for a well-loved patient who has just passed away. As you read this nurses all over the world are saving lives.
Let’s make sure that they know, that we know, how special their work is and how much we appreciate them.
[quote][p][bold]999medic[/bold] wrote: Whilst this is an horrific example of care, we must remember that the hospital treats tens of thousands of patients every year with out problems. There is no excuse for the this lady or her family to have suffered, but remember one thing junior drs come and go and it's the nurses who have to look after both them and the patient and staffing is appalling. I would challenge anyone not connected to health care to spend one week shadowing a mau nurse then see how difficult it gets.[/p][/quote]Absolutely correct. Nurses are being scorned for being late with medicine, and yet are holding their bladder because they do not have time to use the toilet, and starving because they missed lunch. They are being peed on, puked on, shat on, bled on, bitten, hit and yelled at and are missing their families while taking care of yours. They may even be crying inside for a well-loved patient who has just passed away. As you read this nurses all over the world are saving lives. Let’s make sure that they know, that we know, how special their work is and how much we appreciate them. nelson1
  • Score: 11

10:21pm Thu 27 Mar 14

owiseone says...

Yes this very sad and lessons will be learnt , but equally the family could take note. they tried for 8 days to speak to a doctor and complain of lack a care plan . SORRY but if my mother was admitted I would make sure staff knew of her dementia I would NOT wait 8 HOURS let alone 8 DAYS to speak to a doctor . . and why wouldnt you help dress and make a bed , possibly help to feed YOUR relative .
A caring society we live in . but then it is always easy to blame nurses and doctors
Yes this very sad and lessons will be learnt , but equally the family could take note. they tried for 8 days to speak to a doctor and complain of lack a care plan . SORRY but if my mother was admitted I would make sure staff knew of her dementia I would NOT wait 8 HOURS let alone 8 DAYS to speak to a doctor . . and why wouldnt you help dress and make a bed , possibly help to feed YOUR relative . A caring society we live in . but then it is always easy to blame nurses and doctors owiseone
  • Score: -2

11:35pm Thu 27 Mar 14

Mathslove says...

You demonstrate what a remarkably caring society we are living in, to slate a family you know next to nothing about that are grieving over a loved one who's through No fault of their own died a undignified and distressing death. When senior medical and nursing professionals have admitted major failings and they've been endorsed by an independent expert such as a coroner (and a very experienced one in Keith Wiseman) then I think it's absolutely abhorrent to apportion blame to a family who were actively seeking out information that should have been given to them anyway as a matter of course. I feel the family has shown enormous strength to query these downfalls at such a hard time for them. From the details above it appears they stated their case in an admirable fashion and I hope this leads to what is obviously much-needed change.
You demonstrate what a remarkably caring society we are living in, to slate a family you know next to nothing about that are grieving over a loved one who's through No fault of their own died a undignified and distressing death. When senior medical and nursing professionals have admitted major failings and they've been endorsed by an independent expert such as a coroner (and a very experienced one in Keith Wiseman) then I think it's absolutely abhorrent to apportion blame to a family who were actively seeking out information that should have been given to them anyway as a matter of course. I feel the family has shown enormous strength to query these downfalls at such a hard time for them. From the details above it appears they stated their case in an admirable fashion and I hope this leads to what is obviously much-needed change. Mathslove
  • Score: 2

11:13am Fri 28 Mar 14

There's only one 'H' in 'Ampshire says...

The system is broken, not the staff.

Unlimited money is spent on administration and reorganisations of the NHS while the front-line is starved of resources.

In a free at the point of use health care system, whilst being able to treat everyone, demand will always exceed supply

These sort of events will continue to happen when staff are overwhelmed by poor systems constant administrative/gover
nmental meddling and unlimited demand
The system is broken, not the staff. Unlimited money is spent on administration and reorganisations of the NHS while the front-line is starved of resources. In a free at the point of use health care system, whilst being able to treat everyone, demand will always exceed supply These sort of events will continue to happen when staff are overwhelmed by poor systems constant administrative/gover nmental meddling and unlimited demand There's only one 'H' in 'Ampshire
  • Score: 0

1:22pm Fri 28 Mar 14

Joannabanana says...

Find it disgusting family are put into care when they have family to care for them. Stop blaming everyone else and take care of your own mother/father/aunt/u
ncle etc then you can't complain things are wrong.
I worked in a care home and it made me sick how so called family would visit rarely yet demand all sorts.
I will never ever put my parents or uncles into no matter what
Find it disgusting family are put into care when they have family to care for them. Stop blaming everyone else and take care of your own mother/father/aunt/u ncle etc then you can't complain things are wrong. I worked in a care home and it made me sick how so called family would visit rarely yet demand all sorts. I will never ever put my parents or uncles into no matter what Joannabanana
  • Score: 1

1:23pm Fri 28 Mar 14

Joannabanana says...

owiseone wrote:
Yes this very sad and lessons will be learnt , but equally the family could take note. they tried for 8 days to speak to a doctor and complain of lack a care plan . SORRY but if my mother was admitted I would make sure staff knew of her dementia I would NOT wait 8 HOURS let alone 8 DAYS to speak to a doctor . . and why wouldnt you help dress and make a bed , possibly help to feed YOUR relative .
A caring society we live in . but then it is always easy to blame nurses and doctors
Well bloody said!! Like I posted they should be looking after their own family
[quote][p][bold]owiseone[/bold] wrote: Yes this very sad and lessons will be learnt , but equally the family could take note. they tried for 8 days to speak to a doctor and complain of lack a care plan . SORRY but if my mother was admitted I would make sure staff knew of her dementia I would NOT wait 8 HOURS let alone 8 DAYS to speak to a doctor . . and why wouldnt you help dress and make a bed , possibly help to feed YOUR relative . A caring society we live in . but then it is always easy to blame nurses and doctors[/p][/quote]Well bloody said!! Like I posted they should be looking after their own family Joannabanana
  • Score: 0

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