Mums death is going to an Inquest :eek:

[tarababe]

As you will know, my dear dear mum passed away on 10th May in hospital following an infection after a hip replacement...The coroner decided to do a PM and has sent tissue samples for analysis and a letter to me saying they need to establish the cause of death and the circumstances leading up to it.

My husband, who is a police officer, says this is standard procedure after a death in hospital when it wasn't from the cause of admission, i.e. the hip. I do accept this, but I did have a lot of concerns about her treatment and care while she was in there. I have been told the coroner will do a very thorough investigation and although can't account blame onto anyone, if he feels that the hospital could have done more or if they breached any policies, in whatever way, he can elude to that in his report. I can also send a letter to him to outline my concerns and he will also take that into account.

I wanted to outline some on my concerns on here before I put it into writing as see what people think. Although obviously I don't expect any legal advise, so I am going to keep it very basic. I think you understand it when you read it:

Mum admitted to hospital following fall in care home. Spent 10 hours in A & E before being assessed, having an XRay taken and being admitted onto a ward.

Following operation nursing staff found it difficult to keep a cannula in her arm for meds /blood infusion, as she kept pulling it out. Explained she had Dementia and didn't understand.

Mums wound opened up and an infection developed when she was back at care home. District Nurses came in every day to dress the wound and take swabs to ID the type of infection. Was permanently on antibiotics until second fall and re admission to hospital approx 6 weeks later.

Had gone back into hospital as she had pulled off the arm cast. Husband explained to Ortho SPR that she had dementia and didn't understand so they needed to put something else on so she couldn't remove it. Couldn't do propper cast due to type of fracture so tried a different one but again within a few days she pulled that off. Ended up with her arm under her tops to try to stop her moving it.

Had second op on other leg. Developed an infection there and staff again struggled to keep a cannula in her making giving her antibiotics regularly difficult. Explained again she had dementia and didn't understand. We found we had to do this all the time as even they way they spoke to her was if speaking to a person of normal mind set. They expected her to understand what they needed her to do.

We find out (not from hospital contacting us when we were on holiday) that mum taken back to theatre to have wound drained.

Mum taken back to theatre again about two days later as infection still bad and had to have wound cleaned again and prosthetic hip replaced.

Advised mum on ward and ok but on our return from holiday 5 days later, mum had gone rapidly down hill. SPR advised it's due to the infection that they can't get on top of. Continued to try to get antibiotics into her, were not moving her off the ortho ward and would not resuscitate her if she went into respiratory failure.

Few days later, Mums breathing very difficult and had to get nurse to call doctor who was a foundation doctor and who said it wasn't pneumonia. Did not move her from the Ortho ward to a respiratory ward.

Next day mum very poorly and we were advised they had aspirated her chest over night. Next day we were told she was worse and would be advisable for us to come in. Her breathing was still the same with the awful chest rattle as it had been for ages now. They did a portable chest Xray and told us that evening that there was some infection on her chest and that her arm had not healed from the break. They moved her into a private room. Mum passed away two days later.


Now, sorry it's long but my concerns re her treatment are as follows:

We only saw the Senior reg twice, on our return from holiday when mum had rapidly gone down hill and then a few days later to advise they were still battling to save her. After that we only saw a junior doctor and it was her that told us they were putting an end of life care plan into place. We never saw the consultant and constantly found it impossible to speak to anyone higher than the sister, none of whom seemed to be able to do anything. When mums breathing was bad while we were on holiday my brother told one of the ODP's who said she had noticed and spoken to a nurse who had bleeped the doctor. Why did the nurses not see this and why wasn't mum moved onto a respiratory ward where she may have been checked more regularly than on an ortho ward that was obviously understaffed and busy.

If they knew she was pulling the cannula out, isn't it up to their experience as hospital staff to try to find another way of getting antibiotics into her. They seemed to have no idea what to do, even getting the anaesthetist to try a venflon, but even that didn't seem to work for reasons we don't know. Surely getting antibiotics into her were curtail to her getting better or not.

I really feel that their lack of knowledge on dementia did not help mum in any way and although may not be the reason she passed, but surely it had to contrubute to how she was or wasn't cared for.


Sorry for the long rant, but I really feel there is so little understanding of dementia in hospitals where they are supposed to be the experienced staff. My husband said they should know on an ortho ward and the majority of their patients will be elderly as they were when we visited each time. If the nurses don't get trained, then maybe it's something the trust should be looking at.

 

[Carabosse]

Tarababe, i'm sorry to hear you lost your mum and although having an inquest into (hopefully) finding the causes leading up to your mums death is the last thing you want, it may help you get the answers you want. I have been present at one autopsy so far in my training and I can tell you the coroner will treat your mum with the respect she deserves, we are told to treat the person as you would want your own loved one treated, they will be very thorough in the tests they will perform hopefully (as I mentioned) leading to answers as to why certain things happened or did not happen.
You very rarely get to see the consultant except when the person has been admitted or if the relatives of the person who is in hospital asks to see someone who is not a junior doctor even then it will probably be the senior registrar, it is not ideal that junior doctors are left to do a lot of stuff on the wards but they do have a good knowledge of the ward they are covering although we don't know everything and can call on the senior registrar if needed.
Yes your husband is right the majority of people on an ortho ward are likely to be elderly (not always the case) and should know how to look after the person concerned, and yes the level of Dementia knowledge in some nurses (and doctors) is surprisingly sparse, we get told the basics and that's it, but because my mum has Alzheimer's I have slightly more knowledge than some of my colleagues, in an ideal world and with the rise in the number of people getting Dementia the teaching of how to look after/ care for a person with the condition should be top priority for the likes of ortho/ geriatric/ A&E/ surgery wards.
I feel like I should be apologising to you on behalf of my colleagues as I feel they have let you down and most of all they have let your mum down. I hope the inquest gives you the answers you are looking for and that the hospital are held accountable.

 

[rjm]

I really feel that their lack of knowledge on dementia did not help mum in any way and although may not be the reason she passed, but surely it had to contrubute to how she was or wasn't cared for.:confused

Hi Tarababe,

I am sorry that you are going through the stress of an inquest on top of dealing with your mum's death, it is a double whammy that most don't face. However, an inquest is an opportunity for an individual's death to provide an improvement in care for the still living. I think the coroner would be most interested in your view. I wouldn't expect a miraculous overhaul of the system but if the point is made often enough there may be an eventual realisation that more education on dealing with those with dementia is needed.

 

[sue38]

Hi Tarababe,

I'm not sure if what you've written above is exactly what you're going to say in your statement, but I wonder if it would help someone reading the background of your mum's care for the first time if you put it into a timeline, e.g.

August 2012

04.08.12 Mum admitted to hospital following fall in care home. Spent 10 hours in A & E before being assessed, having an XRay taken and being admitted onto a ward.

06.08.12 Following operation nursing staff found it difficult to keep a cannula in her arm for meds /blood infusion, as she kept pulling it out. Explained she had Dementia and didn't understand.

20.08.12 Mums wound opened up and an infection developed when she was back at care home.

20.08.12 - 30.08.12 District Nurses came in every day to dress the wound and take swabs to ID the type of infection. Was permanently on antibiotics until second fall and re admission to hospital approx 6 weeks later.

Early November 2012

Following second fall mum readmitted to hospital ...

I think the short sentences you have used are good and keep it relevant.

This factsheet on Care on a hospital ward might also be helpful when considering what care your mum (or didn't) receive.

 

[chris53]

Hello Tarababe, I just wanted to acknowledge your post and "bump" this post up on the forum, am so very sorry you and your family are going through this dreadful time after your sad loss of mum, I hope you can get answers for your questions and find peace and closure after all this time.
My thoughts are with you.
Chris x

 

[TinaT]

I would second Sue38's suggestion that you use a time line to clarify what was happening step by step. This makes it far easier to understand what is a complex series of events.

xxTinaT

 

[tarababe]

Tarababe, i'm sorry to hear you lost your mum and although having an inquest into (hopefully) finding the causes leading up to your mums death is the last thing you want, it may help you get the answers you want. I have been present at one autopsy so far in my training and I can tell you the coroner will treat your mum with the respect she deserves, we are told to treat the person as you would want your own loved one treated, they will be very thorough in the tests they will perform hopefully (as I mentioned) leading to answers as to why certain things happened or did not happen.
You very rarely get to see the consultant except when the person has been admitted or if the relatives of the person who is in hospital asks to see someone who is not a junior doctor even then it will probably be the senior registrar, it is not ideal that junior doctors are left to do a lot of stuff on the wards but they do have a good knowledge of the ward they are covering although we don't know everything and can call on the senior registrar if needed.
Yes your husband is right the majority of people on an ortho ward are likely to be elderly (not always the case) and should know how to look after the person concerned, and yes the level of Dementia knowledge in some nurses (and doctors) is surprisingly sparse, we get told the basics and that's it, but because my mum has Alzheimer's I have slightly more knowledge than some of my colleagues, in an ideal world and with the rise in the number of people getting Dementia the teaching of how to look after/ care for a person with the condition should be top priority for the likes of ortho/ geriatric/ A&E/ surgery wards.
I feel like I should be apologising to you on behalf of my colleagues as I feel they have let you down and most of all they have let your mum down. I hope the inquest gives you the answers you are looking for and that the hospital are held accountable.

Hi Carabosse. No need to apologise at all. It's not really the nurses or doctors fault that their knowledge is not up to speed with Dementia. When she was admitted onto the ward we advised them about this and asked if they would ensure she got her medication for Alzheimer's. It took four days before she was given it and we could see a hugh change in her being more confused and distressed in that time. Maybe due to being in hospital but who knows? I do feel that at least there should be procedures in place for this kind of patient and they should at least be aware of the basics like added confusion and distress of a strange place and loud noisy wards etc. Not understanding why they are there or where they actually are. My mum was never aggressive with Alzheimer's so was possibly easier to be dealt with but for that reason I feel she was left alone for long periods of time, which isn't helping to reassure someone in that state. This is something the Trust should be looking at.

Hi Tarababe,

I am sorry that you are going through the stress of an inquest on top of dealing with your mum's death, it is a double whammy that most don't face. However, an inquest is an opportunity for an individual's death to provide an improvement in care for the still living. I think the coroner would be most interested in your view. I wouldn't expect a miraculous overhaul of the system but if the point is made often enough there may be an eventual realisation that more education on dealing with those with dementia is needed.

Thanks RJM, I don't expect a miracle but I think they should be made aware, at least it may help someone else not be in that position in the future.

Hi Tarababe,

I'm not sure if what you've written above is exactly what you're going to say in your statement, but I wonder if it would help someone reading the background of your mum's care for the first time if you put it into a timeline, e.g.

August 2012

04.08.12 Mum admitted to hospital following fall in care home. Spent 10 hours in A & E before being assessed, having an XRay taken and being admitted onto a ward.

06.08.12 Following operation nursing staff found it difficult to keep a cannula in her arm for meds /blood infusion, as she kept pulling it out. Explained she had Dementia and didn't understand.

20.08.12 Mums wound opened up and an infection developed when she was back at care home.

20.08.12 - 30.08.12 District Nurses came in every day to dress the wound and take swabs to ID the type of infection. Was permanently on antibiotics until second fall and re admission to hospital approx 6 weeks later.

Early November 2012

Following second fall mum readmitted to hospital ...

I think the short sentences you have used are good and keep it relevant.

This factsheet on Care on a hospital ward might also be helpful when considering what care your mum (or didn't) receive.

Sue I totally agree and there is even more that I have not mentioned on here since I was trying to keep it as a brief summary.... I had a quick look at the fact sheet, we were not aware that we should have looked this information up as you wouldn't not having been in this position before. To be honest we expected the medical professionals to know how to deal with and care for a dementia patient, but oh, how wrong we were. We constantly had to tell them how to be with her and it was a constant up hill battle. We never saw a mental health nurse/team and didn't even speak to a palliative care team/nurse after were were told this was what they were doing. It was never offered and we didn't know to ask.

Hello Tarababe, I just wanted to acknowledge your post and "bump" this post up on the forum, am so very sorry you and your family are going through this dreadful time after your sad loss of mum, I hope you can get answers for your questions and find peace and closure after all this time.
My thoughts are with you.
Chris x

Thank you Chris it is very much appreciated.

I would second Sue38's suggestion that you use a time line to clarify what was happening step by step. This makes it far easier to understand what is a complex series of events.

xxTinaT

Will do Tina, thanks for replying.