Coroner: ‘Unable to find that neglect contributed to death’

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AN inquest into the death of an 81-year-old care home resident – who was admitted to hospital with a ‘significant’ pressure sore – has been ‘unable to make a finding that neglect contributed to his death’.

But the Coroner, Advocate Mark Harris, confirmed that he would ‘write to various agencies to set out learning points in the hope that this may aid future policies’ regarding pressure sores in healthcare settings in the Island.

The Deputy Viscount’s comments were made as part of the findings and conclusions of the inquest into the death of Roland Edmund Baldwyn Childe, which concluded yesterday.

Mr Childe, who was known as Eddie, died at the Hospital on 13 August 2019.

The inquest, which began on Tuesday, heard that Mr Childe was taken from his care home to the Emergency Department when his health deteriorated a month before his death.

Mr Childe was admitted to hospital on 12 July 2019 with a severe chest infection and sepsis. He had also been suffering from dementia and Parkinson’s disease for five years.

Although Mr Childe’s sepsis was successfully treated, he developed aspiration pneumonia, which is usually fatal in someone so frail, and it was therefore decided to manage his conditions rather than attempt to prolong his life.

He died naturally at the hospital on 13 August, with aspiration pneumonia due to Parkinson’s disease given as the primary cause.

However, an infected pressure sore gave rise to safeguarding concerns.

Evidence from Dr Michael Richardson, a consultant physician at the Hospital, was read at the conclusion of the inquest. He said that the pressure sore was ‘a significant contributory factor’ to Mr Childe’s death.

The inquest also heard evidence from various professionals involved in Mr Childe’s care in the months leading up to his death, including his GP, tissue viability nurses from both Family Nursing and Home Care and the Hospital, and the former clinical director of the Caring Homes group.

Throughout the two days of the inquest, many of the medical professionals voiced concerns about the severity of Mr Childe’s pressure sore upon his admission to hospital.

The inquest also heard entries from Denise Childe’s diary from when she was visiting her husband in L’Hermitage care home, and later Beaumont Villa.

She repeatedly referred to being ‘sad and worried’ about her husband’s worsening pressure sore, and was concerned that he was spending too much time in his wheelchair.

‘For more than nine months, my husband suffered excruciating pain,’ she said. ‘How could this have happened?’

Concluding the inquest, the Deputy Viscount said that he was ‘unable to make a finding that neglect contributed to [Mr Childe’s] death’ as there was ‘no gross failure to provide medical attention’.

However, he admitted that more could have been done with the benefit of hindsight.

‘Could more have been done?’ asked Advocate Harris, ‘With the benefit of hindsight, yes, probably. Any of the agencies involved could have escalated the issue.’

The Deputy Viscount explained that education around the issue of pressure sores had improved since Mr Childe’s death in 2019, particularly following the introduction of an Island-wide Pressure Ulcer Prevention and Management Framework in September 2021.

He added: ‘Every witness [at the inquest] has told us about the learnings that have come from Eddie’s death.’

Offering his condolences to Mr Childe’s family, Advocate Harris confirmed that he will ‘write to various agencies to set out learning points in the hope that this may aid future policies’.

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