The inquest touching upon the death of 89 year old Sylvia Thompson concluded this Monday at Wakefield Coroners Court. Assistant Coroner Oliver Longstaff recorded a short form conclusion of Natural Causes Contributed to by Neglect.
In order for neglect to be found in an inquest, the following must be established;
The Coroner must find that there was a gross failure to provide adequate care to someone in a dependent position, such as due to youth, age, illness, or incarceration. Here are the key points:
Dependent Position: The deceased must have been in a position where they relied on others for basic needs.
Gross Failure: There must be a significant failure to provide essential care, such as nourishment, hydration, medical attention, shelter, or warmth.
Causal Connection: The neglect must be connected to the cause of death on the balance of probabilities.
This investigation found that Mrs Thompson suffered from Lymphedema and skin ulcers. A small ulcer on her foot was properly treated in the community by way of regular assessment, cleaning and dressing which prevented Mrs Thompson from suffering an infection.
However, Mrs Thompson was admitted to St James Hospital, Leeds on the 31 October 2023 with dizziness and lower abdominal pain. Shortly after admission she was transferred to ward J14 where despite her history, there was a failure to recognise, assess or treat the ulcer on her foot. Sylvia was discharged on the 16 November 2023 and on the following day, when she was assessed by her community care team, they discovered a significant and horrific deterioration of the ulcer on her foot. They described how the anti-slip hospital sock was stuck to the wound which was oozing with pus and blood.
The Court heard evidence that during the whole 16 days that Mrs Thompson spent in hospital, she didn’t receive any nursing care for the ulcer on her foot. Ultimately the infection progressed, and Mrs Thompson was diagnosed with Osteomyelitis (deep infection into the bone) which spread to her abdomen and she sadly died on the 10 January 2024.
Her daughter Christine, who had only 18 months earlier attended her father’s inquest in Wakefield, said the following:
Having experienced my father’s inquest it was important to me that my mum’s voice should be heard and that clear learning outcomes be actioned. My mum lived through cancer, losing both of my younger brothers in April 2019 and February 2023 as well as losing her husband of 67 years in September 2022. She was determined to continue to live her life to the full. Even with a diagnosis of Dementia 6 years earlier, this was not going to stop her living as independently as she could. With the amazing support she received from her carers at Aegis Care Solutions and support from Forward Leeds, we were able to put strategies in place that meant my mum could continue to safely live at home on her own.
My mum held a special place in all our hearts and she loved family get togethers, attending birthday parties for her great-grandchildren and afternoons out at her local Waitrose for toasted teacake and tea, a favourite of her and my dad’s, or to the local carvery where staff knew my parents and ensured they were welcomed and met their needs.
I feel privileged that I had my mum in my life for so long and that she never forgot who we were. I know others are not so fortunate. She and my dad were great advocates for those who didn’t have a ‘voice’ and I know she will be proud that I am now looking to work with charities like Dementia Uk and Alzheimer’s Society to see how I can use my lived experience to raise awareness in hospital settings of how patients with limited capacity or impairment, can be better supported by increasing understanding in staff to ensure they feel better equipped to provide the best experience for patients in these situations.
My daughter, who works in the NHS as a stroke physiotherapist, once said ‘patients with dementia may not always remember what you said to them but they will remember how you made them feel’. This was true for my mum and it’s a mantra I tell everyone I meet dealing with a loved one with dementia.
My mum endured a long period in hospital and I was shocked to see that many staff were unable to make provision for her dementia. There was little understanding amongst staff in managing her behaviours which were impacted due to the change in environment, being in pain and not being able to relate to her in way that she would trust and therefore comply by taking medication for example. Having her cries ignored when she was clearly in pain, being seen as a bit of a ‘nuisance’ and being told that ‘her pain was in her head’ added to the stress of the situation. All of this was down to a lack of understanding of her mental health condition. My mum was clear as to which staff she would engage willingly with and others she was wary of – and when asked why she didn’t wish to have a certain individual support her, she couldn’t articulate why but said ‘I don’t think she likes me, so don’t make a fuss’. Patients like my mum with additional needs don’t ask to be in this situation, but with a little patience, compassion and time, working with family members to look at how they can better supported, will bring about a more positive outcome for both patient and staff alike.
Mum’s dementia meant that she lost her filter at times and often would say things out loud that she might otherwise have just internalised, sometimes requiring us to apologise, but always taken the right way once people understood the reason behind that behaviour. She never lost her sense of humour and would still remind us that we weren’t too old for a telling off if we got things wrong! She was always mum, aunt, grandma or great grandma who loved life and lived it to the full.
My mum was unique – one of a kind – and she deserved better. We miss her every single day. The learnings from this unnecessary and appalling experience must not be lost and must be spread wider than Leeds Teaching Hospital NHS Trust.
‘I am here, I feel, but I can’t always express myself as I used to. Live in my moment, not yours’
The family were represented by our Director and Head of Inquests, Gareth Naylor and Counsel Alan Wier of Parklane Plowden Chambers.
