Two ‘gross failures’ of temporary nurses contributed to the deaths of disabled women in the nursing home

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Two temporary nurses whose “gross failures” contributed to the death of a disabled woman were allowed to continue working in a care home because they “knew the residents well,” a coroner has heard.

Rachel Johnston, 49, had all of her teeth surgically extracted at Kidderminster Hospital on October 26, 2018 due to severe decay, which left her in pain and struggling to eat.

Despite being happy and “singing” to herself upon her discharge, Miss Johnston fell asleep on the journey back to Pirton Grange Care Home, near Pershore, Worcestershire, and never regained consciousness.

Rachel Johnston, 49, (pictured) had all of her teeth surgically extracted at Kidderminster Hospital on October 26, 2018

Rachel Johnston, 49, (pictured) had all of her teeth surgically extracted at Kidderminster Hospital on October 26, 2018

Pasqueline Gill, quality assurance manager for Holmleigh Homes, said both nurses had been referred to the NMC in February and `` prior to that, it was assumed it would be the agency's responsibility to refer. ''

Pasqueline Gill, quality assurance manager for Holmleigh Homes, said both nurses had been referred to the NMC in February and `` prior to that, it was assumed it would be the agency's responsibility to refer. ''

Pasqueline Gill, quality assurance manager for Holmleigh Homes, said both nurses had been referred to the NMC in February and “ prior to that, it was assumed it would be the agency’s responsibility to refer. ”

She died on November 13, 2018, 10 days after her livelihood was cut off, with her mother by her side (Rachel Johnston pictured with her mother)

She died on November 13, 2018, 10 days after her livelihood was cut off, with her mother by her side (Rachel Johnston pictured with her mother)

She died on November 13, 2018, 10 days after her livelihood was cut off, with her mother by her side (Rachel Johnston pictured with her mother)

She died two weeks later after her family decided to withdraw the livelihood.

In an inquest conducted last month, senior coroner David Reid concluded that “gross failures” by two nurses in the nursing home amounted to failure to provide basic medical care, which contributed to Miss Johnston’s death.

Mr. Reid concluded that after surgery, nurses Sheeba George and Gill Bennett had not routinely checked Miss Johnston’s pulse, heart rate, and blood oxygen levels, and then made their mistakes worse by not receiving “emergency medical care.”

He said, “I’m afraid in either case the outage was so severe, so total, and complete – so clearly not just any simple mistake – that it can only be described as a gross failure.”

But during the final act of the hearing – postponed to Friday due to a lack of availability of witnesses – the inquest heard that the agency’s two nurses had been allowed to continue working from home.

Despite the nurses telling the nursing home manager in a 2018 lessons learned review that they had not conducted baseline observations, until February 2021 – more than two years later – no one had referred them to the nursing and Midwifery Council (NMC) professional body. ). .

The care home manager, Jane Colbourn, who gave testimony, said that following Ms. Johnston’s death, six policies had been put in place involving staff training and audits, with the existing rules ‘tightened up’ and a new clinical manager was appointed to supervise the nursing staff.

Mrs. Colbourn said, “We had the policy in place and they (the nurses) knew they had to follow the policy.

Lizanne Gumbel QC, on behalf of Mrs. Johnston’s family, asked the manager: ‘But what nurse (Sheeba) George said, when I asked her,’ Does it make a difference now that there is a protocol, ‘she said,’ A protocol is very just sense – I knew how to do those things as a certified nurse anyway ‘.

“So policy making is not going to solve the problem, to the extent that individual nurses ignored those basic medical care, right?”

Mrs. Colbourn replied, “No.”

To keep the nurses on, the manager said, “They were regular nurses who knew those residents well and it’s better to have those nurses than other nurses who don’t know the other 34 residents at all.”

Miss Gumbel asked, “Did you think it appropriate that nurses whose level of care was so low, so dangerous, should continue to care for your other patients just because they knew them?

“It seems extraordinary that you would leave other patients at that risk.”

Mrs. Colbourn replied, “I personally didn’t feel like they were in danger.”

Mr. Reid was informed that the nurses were finally referred to the NMC by the owner of the Holmleigh Homes nursing home on February 23 of this year.

Miss Johnston, who suffered brain damage after contracting meningitis as a baby, was asleep for 42 hours before the staff raised the alarm and the paramedics took her to the hospital.

It was not until 2 p.m. on Sunday, October 28 that the staff called 999 and called an ambulance.

By the time she arrived at Worcestershire Royal Hospital, scans showed she had suffered an irreversible hypoxic brain injury.

She died on November 13, 2018, 10 days after her life support was turned off, with her mother by her side.

Pasqueline Gill, quality assurance manager for Holmleigh Homes, said both nurses had been referred to the NMC in February and “ before that it was assumed it would be the agency’s responsibility to refer, ” or the NHS.

Ms. Gill told the coroner, “I can’t answer why they stayed employed and kept using (the house) them.”

In conclusion, Mr. Reid said, “I am not satisfied that there are sufficiently robust policies and procedures that can ensure that, if there are sufficiently serious concerns about a nurse’s behavior, a disciplinary procedure is put in place.”

The coroner ordered a future death prevention report to Holmleigh Homes, saying it was “ concerning ” that the nurses had not been reported to the NMC before February.

A health watchdog inspection in November 2019 rated Pirton Grange as ‘good’ for care overall.