‘Gross failures’ contributed to disabled woman’s death, coroner concludes

The death of a disabled woman days after she had all her teeth surgically removed was contributed to by the neglect of care home nurses, a coroner has concluded.

Rachel Johnston, 49, had her teeth extracted at Kidderminster Hospital on October 26 2018 due to severe decay, which had been causing her pain and difficulty eating.

Despite being happy and “singing” to herself on discharge, Miss Johnston fell asleep on the journey back to Pirton Grange Care Home, near Pershore, Worcestershire, and never regained consciousness.

She died two weeks later after her family decided to withdraw life support.

Senior coroner David Reid found “gross failures” by two nurses at the care home amounted to a failure to provide basic medical care, contributing to Miss Johnston’s death.

Delivering a narrative conclusion at Worcestershire Coroner’s Court on Thursday, Mr Reid said: “Rachel died as a result of complications of necessary surgery, to which neglect contributed.”

He added the failure of a 111 out-of-hours clinician to ask “direct questions” about her condition over the phone the day after her discharge amounted to a lesser care failure.

The coroner heard that the home’s record-keeping was patchy and observations were not routinely recorded.

Concluding a four-day inquest, he said care home nurses failed to carry out basic physiological checks, then failed to seek emergency medical care quickly enough.

The coroner said care home healthcare professionals Sheeba George and Gill Bennett failed to routinely check Miss Johnston’s pulse, heart rate and blood oxygen levels after the surgery.

It was not until Sunday October 28, at 2pm, that staff dialled 999 and called an ambulance.

Mr Reid said: “I find it should have become obvious to nursing staff at Pirton Grange that from the evening of Saturday, Rachel’s condition was a cause of serious concern and that emergency assistance should have been sought from that point onwards.

“I am quite satisfied, on the balance of probabilities, firstly that the two nurses’ failure to ensure that regular sets of observations were carried out and documented, and secondly the failure by those nurses to seek emergency assistance from Saturday evening, amounted to a failure to provide basic medical attention.

“I am afraid in each of those two instances the failure was so serious, so total and complete – so patently not just a simple error – it can only be described as a gross failure.

“I am satisfied that if Rachel had been admitted to hospital that (Saturday) evening, she would probably have survived.

“It follows the two gross failures which I have identified did indeed contribute to Rachel’s death on November 13 2018.”

A post-mortem examination found Miss Johnston died after her brain was starved of oxygen over a prolonged period.

Miss Johnston, who suffered brain damage after contracting meningitis as a baby, had been asleep for 42 hours before staff raised the alarm and paramedics rushed her to hospital.

By the time she arrived at Worcestershire Royal Hospital, scans showed she had suffered an irreversible hypoxic brain injury.

She died 10 days after her life support was switched off on November 2, with her mother at her side.

The coroner said Miss Johnston was “blessed with a close family” and “despite all the challenges which Rachel had to face, she was a lively, happy woman who loved music, theatre and the company of other people”.

Earlier in the week, Ms Bennett gave evidence of seeing Miss Johnston at 10.30am on the Saturday “gurgling” and with “watery blood coming out of her mouth”, the coroner said.

Mr Reid added it was “truly baffling” why the trained nurse “did not proceed to carry out any physiological observations”.

He said it was “even more baffling” that she “readily accepted she should have”, but was “simply unable to explain why she did not”.

Mr Reid said he “did not find Sheeba George to be a reliable witness” after she gave evidence about recording Miss Johnston’s observations on a “piece of paper”, which had since been lost.

He added: “The story… does not, in my view, have the ring of truth, not least because it is only now, some two and half years later, that she says she remembered (doing) it.

“I am satisfied, on balance, that Ms George did not do the other observations she claims that she did.

“No doubt if Pirton Grange had had in place a more robust system of policies, procedures, training and auditing, both those nurses would have carried out and recorded regular observations on Rachel over these two days but that does not, I stress, excuse their own failures in that regard.”

Lawyers for the care home – rated as good in its most recent Care Quality Commission inspection – told the inquest that procedures had since been tightened.

Speaking afterwards, Miss Johnston’s mother Diana said: “What happens time and again to the families of people with learning difficulties is that we get sidelined by medical professionals – even when we clearly know the person involved the best and love them the most.

“Rachel was specifically moved to Pirton Grange (in 2013) because, as a nursing home, it would be able to give her medical care if she needed it.

“When she needed it, they failed her and she died.”

Caron Heyes, from law firm Fieldfisher, representing Miss Johnston’s family, said: “What came out clearly in the evidence is that Rachel would still be here if she’d been cared for properly – she was fit, she was healthy and she was a fighter.”