When Peter James McBride, 86, was admitted to Port Pirie Hospital in 2015, staff failed to properly care for his bedsores, which ultimately lead to his death from organ failure, according to a Coroner’s report.

It’s every family’s worst nightmare: that their frail and elderly loved one experiences pain and great suffering at the end of their life. And yet this is what occurred in Mr McBride’s case – his bedsores were of such a magnitude that they would have caused him agony.

Mr McBride’s suffering is all the more concerning because it occurred in a hospital, where it would be entirely appropriate to expect he would be well cared for. Also compounding the family distress in this case must be the coroner’s claim that Mr McBride’s death was “almost certainly” preventable.

Bedsores not properly identified or treated

Mr McBride was admitted to Port Pirie Hospital on 7 February 2015 after falling twice in the one day at the home where he had lived with his wife for more than 60 years.

He remained in the hospital for 61 days, as he waited for a place in an aged care facility, and during that time he developed bedsores.

After 61 days, Mr McBride was admitted to Royal Adelaide Hospital, and after two days there, he died from infections that occurred as a result of his bedsores.

The doctor who reported the “unexpected” death to the coroner noted “concern re medical neglect”.

Coroner Mark Johns, notes in his report that when Mr McBride was admitted to Port Pirie Hospital, his wound was not adequately assessed, and it was only after being in hospital for a week that it was properly attended to. Instructions to apply “pressure area care” every four hours were not carried out. And in addition, Mr McBride was only supplied with a pressure mattress more than a month after the wound was first observed because of a shortage of such mattresses.

Mr McBride’s death was “preventable”

The expert overviewer of the case, Professor Whitehead, wrote that Mr McBride’s death was “almost certainly” preventable, and was caused by the consequences of the pressure wound. He said Mr McBride’s lack of mobility during his stay at Port Pirie Hospital was also notable, and was made worse by the use of sedatives.

Professor Whitehead summarised the case as follows:

“Mr McBride has died of a number of complications of excessive bed rest and poor nursing care. This has been manifested by the acceleration and development of his pressure area. There are a number of failures of good nursing care when related to pressure area management in particular the non-use of preventive strategies but rather a reactive strategy once the ulcer had developed, the excessive use of antipsychotics and the poor mobilisation of the patient.”

Frail, elderly patients should be “bread and butter” of regional hospitals

The coroner said that small regional hospitals have the appropriate policies and procedures available to them, and they should be able to provide care to the “frail and elderly” – which are their most common patients.

“If they cannot manage pressure area care well, it is difficult to see why not. It should be their bread and butter,” he said. “Competent execution” is all that is required, he said.

Coroner’s recommendations

The coroner recommended that Port Pirie Hospital acquire more pressure mattresses and that SA Health make GPs aware that catheters can double the risk of delirium and promote bed-centered care, and that urinary tract infections do not require antibiotic treatments when there is no evidence of a more generalised infection.

A spokesperson for SA Health said, “Our sincere condolences go out to the patient’s family and SA Health will be providing a formal response to the Coroner’s recommendations within six months.

“However this year Port Pirie Hospital purchased an additional two pressure mattresses, and is in the process of finalising a request for more pressure mattresses.”

This article was edited on 11 September 2018 to include a statement from SA Health.

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