The carers of a 98-year-old woman were unable to spot the tell tale signs that she was dying.
Joan Richardson was living in supported accommodation when her health quickly deteriorated. In April, 2020, the "frail" woman's condition declined to the point where she needed more support with her personal care, was not eating enough for her needs and started to show signs of confusion.
An ambulance had first been called on April 23, 2020, by the warden of the complex, but the paramedics determined Joan did not need to go to hospital but needed help with her personal care. The following day the local authority determined she would need home care, with it being provided until a private care provider was able to take over on April 29.
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During the care of the provider, Joan was not seen out of her bed after April 30, and carers were unable to change her regularly or provide pressure area care or relief which was necessary for Joan who was "frail, elderly, immobile and incontinent" as she often refused help.
The 98-year-old was taken to hospital on May 4 after carers became concerned that she was becoming less responsive and that her condition was continuing to deteriorate. When she was admitted, she was diagnosed with pneumonia, found to have deep tissue wounds to her sacrum (lower back) and a fractured neck of femur (hip).
Three days later, when Joan, from Huyton, was deemed as clinically stable as possible, she underwent surgery to her hip. Following her surgery, Joan's condition continued to deteriorate before she died in Whiston Hospital on May 18, 2020.
In a prevention of future death report written by senior coroner Julie Goulding, it was noted that her care "should have been escalated as being of significant concern", as well as the fact action should have been taken so that Joan could receive care for the sores on her pressure areas.
It also said: "A carer did seek advice from a senior member of staff who visited Joan and subsequently ambulance was called during the early morning visit 04/05/2020 when Joan was admitted to hospital."
Ms Goulding wrote that the matters should have been escalated around her deterioration, as well as no comprehensive plan of care, risk assessment, pressure area care plan, falls assessment or care plan put in place by Litch Care Services. It was also noted that there was no record of the pressure ulcers Joan had suffered, with no assessment of skin breakdown while she was in the care of Litch Care Services.
The report said: "Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required."
Since the inquest, the care service provider has written an action plan where it said: "We routinely monitor people's care and treatment to continuously improve it. We ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves."
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