In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mr James McNeil (DOB 14th September 1935) died at 08:30 hours on the 22nd of October 2008 at Belhaven Hospital, Dunbar. The cause of death was (i) bronchopneumonia; (ii) pressure sores on back, ischemic heart disease, and dementia.
In 1989, Mr McNeill was diagnosed with Alzheimer's disease, and his condition eventually deteriorated in 2007. On 18th April 2008 Mr McNeill was admitted to Lennel House Nursing Home, Coldstream; Lennel House was a nursing home owned and operated by Guardian Care Homes (UK) Ltd. On admission to Lennel House an Admission Assessment Form was completed by the duty staff nurse. The assessment covered, inter alia, the risk of pressure sores; Mr McNeill was assessed as being at high risk of developing pressure sores.
On 19th May 2008 two blood blisters were noticed on Mr McNeill's sacral cleft. These were the first manifestations of the early stages of pressure sores. In the course of the following days the blisters were treated with creams and dressings. However, the area of the wound, which was measured and recorded daily, increased. By 30th May 2008 the blisters measured 3 x 1.5cm and 1 x 1cm and were recorded as being necrotic and producing an odour, signs consistent with infection. By 9th June 2008 the measures put in place produced no improvement and the odour from the wound was now described as offensive. On 11th June 2008 the district nurse visited Lennel House by prior arrangement. The wound now measured 13 x 4.5cm and was discharging thick yellow puss. A hole had appeared in the sacral cleft from which fluid leaked. The district nurse arranged for Mr McNeill to be examined by a GP which examination was conducted on 12th June 2008. As a result of this examination the GP arranged for Mr McNeill to be admitted to the Borders General Hospital on 12th June 2008 in order to obtain a surgical opinion. On 13th June 2008 surgical debridement of Mr McNeill's pressure sore wound was carried out. The operating surgeon considered the wound to be serious and described the operation as a "planned emergency". In his experience of having carried out 12 or so pressure sore debridements over the years, this was described as the worst which he had encountered.
Mr McNeill remained at Borders General Hospital until 24th September 2008 when he was transferred to Roodlands Hospital, Haddington. On 20th October 2008 Mr McNeill was transferred to Belhaven Hospital in Dunbar. At about 06:00 hours on Wednesday 22nd October 2008 nurses attended on Mr McNeill to administer medication, including morphine sulphate, and prepare him for a bed bath. After about 30 minutes, when in course of being bathed, Mr McNeill's condition deteriorated and he expired in the presence of nursing staff.
The Sheriff noted that from the evidence there could be little doubt that Mr McNeill's care at Lennel House would have benefitted from better and more promptly implemented care plans and risk assessments; from being cared for by nursing staff who had the advantage of better managerial support; better induction procedures; better training especially in respect of pressure sores and the care of the elderly; better dissemination of information regarding policies and procedures; better access to specialist equipment; and from allocated time for communication as between staff on different shifts.
Focusing on Mr McNeill's development of pressure sores, the risk of these developing would almost certainly have been reduced with earlier provision of special mattresses, cushions and organised and recorded positional changing. The Sheriff concluded from the evidence that the latest date when Lennel house nursing staff ought to have contacted the district nurse, or general practitioner, regarding Mr McNeill's pressure sore would have been 4th June 2008. However, the Sheriff noted that in the interim period, key staff had changed at the nursing home and that following the death of Mr McNeill, procedures had been improved radically. For these reasons, the Sheriff considered it inappropriate to make any findings under the Act in terms of section 6(c) and (d).
