An investigation has found that Sandra Miller died after staff at the nursing home she stayed in left a blocked catheter in her, which in turn caused serious infection and sepsis.
Sandra, who had Down’s Syndrome, Alzheimer’s, hypothyroidism and type 2 diabetes, was discharged from the Mortimer House Nursing Home in Bristol in May 2015, reports the Bristol Post.
She was rushed to Southmead Hospital on 15 June, where nurses discovered her catheter was not properly collected, and upon removing it discovered “a large quantity of foul-smelling, pus-like urine drained from the bladder.”
Doctors treated Sandra for sepsis, a respiratory and urinary tract infection, and heart failure, and later discovered that she had an E. Coli infection. She died six days later on 21 June.
The investigation into Sandra’s death discovered that the Milestone Trust owned and operated Mortimer House, who had been in charge of her care, had removed the bag and tubing from Sandra’s catheter and allowed it to drain freely into a pad, which had become practice at the facility as Sandra would frequently become agitated and try to remove the bag.
Despite being warned that this was likely to cause infections, the practice was continued, and her urinary catheter was allowed to drain freely while the open end was tucked into her faecal incontinence pad, which further increased her risk of infection.
The area manager of the Milestone Trust told the court during the inquest that she “could not confirm” if anything had been done in the months following Sandra’s death to stop this practice, and could not explain if procedures had been implemented or if staff had received appropriate training.
Assistant coroner Dr Peter Harrowing has written to the Trust, ordering “urgent action” to prevent staff from allowing catheters to drain freely.
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