Death of 81-year-old to "aid future policies" on bed sore care

Thursday 16 March 2023

Learnings from the death of an 81-year-old care home resident who was admitted to hospital with a pressure sore one nurse described as "one of the most serious I've ever seen" will be used to improve the care received by islanders in future.

The Deputy Viscount confirmed yesterday that he will "write to various agencies to set out learning points in the hope that this may aid future policies" about pressure sores.

Advocate Mark Harris' comments were made as part of the findings and conclusions of the inquest into the death of Roland Edmund Baldwyn Childe, which concluded yesterday.

Mr Childe, who was known as Eddie, died at the Hospital on 13 August 2019.

The inquest, which began on Tuesday, heard that Mr Childe was taken from his care home to the Emergency Department when his health deteriorated a month before his death.

Mr Childe was admitted to hospital on 12 July 2019 with a severe chest infection and sepsis. He had also been suffering from dementia and Parkinson’s Disease for five years.

Although Mr Childe’s sepsis was successfully treated, he developed aspiration pneumonia, which is usually fatal in someone so frail, and it was therefore decided to manage his conditions rather than attempt to prolong his life.

He died naturally at the hospital on 13 August 2019, with aspiration pneumonia due to Parkinson’s Disease given as the primary cause.

However, Mr Childe also had an infected pressure sore on his buttocks which gave rise to safeguarding concerns.

Evidence from Dr Michael Richardson, a consultant physician at the Hospital, was read at the conclusion of the inquest yesterday.

Dr Richardson confirmed that the "significant" pressure sore was the cause of Mr Childe’s "severe sepsis episode" as "no other infection source was noted".

He added that the pressure sore was "a significant contributory factor" to Mr Childe’s death.

Pictured: The inquest was held at International House, The Parade.

The inquest also heard evidence from various professionals involved in Mr Childe’s care in the months leading up to his death, including his GP, tissue viability nurses from both Family Nursing and Home Care and the Hospital, and the former Clinical Director of the Caring Homes group.

Throughout the two days of the inquest, many of the medical professionals voiced concerns about the severity of Mr Childe’s pressure sore upon his admission to hospital.

His GP called the wound "horrendous" and the tissue viability nurse specialist at the Hospital described it as "one of the most serious I’ve ever seen".

The inquest also heard entries from Mrs Denise Childe's diary from when she was visiting her husband in L'Hermitage care home, and later Beaumont Villa.

She repeatedly referred to being "sad and worried" about her husband's worsening pressure sore, and was concerned that he was spending too much time in his wheelchair.

"For more than nine months, my husband suffered excruciating pain," she said. "How could this have happened?"

Mrs Childe added: "To put loved ones into a care home is one of the hardest decisions anyone has to make... I trusted them to care for my husband but, in my opinion, they failed.

"Something from my husband’s death has to be said or done."

Concluding the inquest, the Deputy Viscount said that he was "unable to make a finding that neglect contributed to [Mr Childe’s] death" as there was "no gross failure to provide medical attention".

However, he admitted that more could have been done with the benefit of hindsight.

"Could more have been done?" asked Advocate Harris. "With the benefit of hindsight, yes, probably. Any of the agencies involved could have escalated the issue."

The Deputy Viscount explained that education around the issue of pressure sores had improved since Mr Childe’s death in 2019, particularly following the introduction of an Island-wide Pressure Ulcer Prevention and Management Framework in September 2021.

He added: "Every witness [at the inquest] has told us about the learnings that have come from Eddie’s death."

Offering his condolences to Mr Childe’s family, Advocate Harris confirmed that he will "write to various agencies to set out learning points in the hope that this may aid future policies".

Family Nursing and Home Care — a charity which provided input on the pressure sore framework — said that this week's inquest "helped to identify the need for further detail within the framework" which is due to be reviewed this year.

They explained: "Since Mr Childe’s death, a number of changes to the management and prevention of pressure ulcers across the island have been implemented through the publication of an Island Wide Pressure Ulcer Framework, which intends to promote a standardised evidenced based approach to prevention and management of pressure ulcers. 

"The inquest has helped to identify the need for further detail within the framework, which is due to be reviewed this year. Family Nursing & Home Care will work in partnership with all relevant agencies in its development."