An inquest at Wakefield into 85-year-old Betty Marshall’s death heard it was likely she would not have died had she received proper care at the Mid Yorkshire Hospitals NHS Trust.
Mrs Marshall was being cared for at an understaffed 24-bed intermediate care facility in Pontefract, where nurses struggled to cope and did not have time to properly complete patient records amid an outbreak of Norovirus.
One nurse, who was in tears during the outbreak amid fears she could not cope, described the situation on the ward as an “absolute nightmare”.
The surgical wound on Mrs Marshall’s hip had not healed properly and was infected and weeping pus, but the condition was not noted by nursing staff.
Mrs Marshall, of Batley Road, Kirkhamgate, in Wakefield, underwent a hip replacement operation at Pinderfields Hospital, Wakefield, on December 18, 2010. On December 29, Mrs Marshall was transferred to Monument House in Pontefract to undergo rehabilitation and further assessment and support.
She developed diarrhoea on the evening of December 29 and other patients suffered similar symptoms amid an outbreak of Norovirus.
While at Monument House, Mrs Marshall also developed a pressure sore and was dehydrated – two additional conditions that went untreated. She was also suffering from poor nutrition.
Mrs Marshall’s hip wound broke open on January 14 and she was transferred back to Pinderfields.
Recording a narrative verdict, Deputy assistant coroner Mary Burke said: “Despite full support and treatment, Mrs Marshall’s condition failed to improve and she died on F Ward at Pinderfields General Hospital on January 22 2011 as a result of sepsis which was due to her infected hip wound, which she had sustained as a result of the surgical intervention she had undergone on December 18 2010.”
“It is likely that if Mrs Marshall had received full care and support prior to her re-admisson to Pinderfields Hospital, she would have survived.”
She noted too, that at the time of Mrs Marshall’s admission to Monument House “initial documentary assessments of Mrs Marshall were either not completed or were not completed correctly”.
Nurse Kirsty Shepherd told the inquest the ward at Monument House was “horrendously busy” and confirmed patients were not getting 100 per cent care due to staff shortages.
Ms Burke said: “She (Kirsty Shepherd) confirmed when there was an outbreak of Norovirus, this placed the unit under more pressure. She described the situation as an absolute nightmare. She recalls she was crying down the phone saying she could not manage and cope.”
Orthopaedic surgeon Bern Ketzer told the hearing he would have expected a review to have been carried out on Mrs Marshall’s surgical wound after December 31, followed by daily checks.
Ms Burke, said: “He indicated that the developing infection would have been evident and would have expected treatment would be provided while she was at Monument House. He confirmed it was his view it was likely she would have survived if the infection had been treated.”
Helen Thomson, interim chief nurse at The Mid Yorkshire Hospitals NHS Trust, said: “We carried out a thorough review at the time and we fully recognised that aspects of care fell below the standard that would be expected. On behalf of the trust, I would like to sincerely apologise.
“We have put significant improvements in place at Monument House over recent years. We will also take any further areas of learning from the inquest and take further action as appropriate.”