“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.
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.
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?”
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.
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