'Gross failures' contributed to grandmother's death

Patricia Hendry was discharged from hospital without "basic and critical" information being available

A grandmother died a painful death after “gross failures” of hospital staff and district nurses.

Patricia Hendry left Whiston Hospital in Merseyside with a healing lesion on 28 September 2022.

But “basic and critical information” about the 78-year-old’s condition was not passed on to community nurses, the coroner at her inquest in Liverpool said.

Mrs Hendry died of sepsis just under a month later.

'Fundamental'

The coroner at her inquest at the Gerard Majella Courthouse found neglect had contributed to Mrs Hendry's death.

She had several long-term health conditions, but she had been able to walk and take care of herself until 19 August 2022, when she was admitted to Whiston Hospital after falling at her home in Netherley.

In hospital, she became doubly incontinent, lost weight and developed a painful lesion.

The lesion was healing by the time she was discharged.

Coroner Anita Bhardwaj said her care at the hospital was "appropriate and reasonable", but no home visit was carried out, and a social worker was not told that she was being turned every two hours, including during the night, to prevent pressure sores.

The hospital also failed to explain Mrs Hendry was on medication that increased the amount she urinated, again increasing her risk of developing pressure sores due to her incontinence.

Mrs Hendry went on to develop a painful pressure sore that was severely infected.

Ms Bhardwaj said in her conclusion: "This is basic and critical information that should have been taken account of at the point of discharge and should have been made available to the social worker so that an appropriate care package could be considered.

"This is a fundamental basic requirement and not to do so was a gross failure."

Whiston Hospital did not effectively plan for Mrs Hendry's discharge

Ms Bhardwaj said district nurses from Mersey Care NHS Foundation Trust, assigned to care for Mrs Hendry, failed to recognise how serious her wound was and did not escalate her case to a GP or specialists.

This was a second "gross failure", the coroner said.

"This is fundamental basic care and it is more likely than not had the wound been escalated earlier Patricia would have had a greater chance of survival," she said.

In a statement at the conclusion of the inquest, Mrs Hendry’s family said they were "heartbroken and devastated".

They described her as "a loving wife, mother, grandmother, and great-grandmother, who devoted her life to raising and providing for her family".

"We have been left traumatised, not just because we have lost our mum, but by the way we lost her.

"So many different medical professionals were involved in her supposed care and, as the court has heard, that care fell well short."

The statement added the family hoped Mrs Hendry's case would highlight what went wrong so it "will never happen again".