Rachel Johnston: Care staff unaware dental patient seriously ill

Rachel Johnston died just over two weeks after the operation

A string of failures meant it took care home staff two days to realise a disabled woman who had all her teeth removed was seriously ill, an inquest heard.

Rachel Johnston was bleeding from her mouth, "gurgling" and had been asleep for 42 hours before staff dialled 999.

The alarm was raised when her oxygen level was found to be dangerously low.

Agency nurse Gillian Bennett told the hearing in Worcestershire: "I thought, 'we need help, quick'."

Ms Johnston never regained consciousness and died just over two weeks later of a hypoxic brain injury.

The 49-year-old had all her teeth removed due to severe decay at Kidderminster Hospital on 26 October 2018. She was discharged to Pirton Grange Care Home, near Worcester, four hours later.

Although in high spirits on the journey home with her mother, she fell asleep 10 minutes before arriving.

Ms Bennett was working the next day and was told in a handover Ms Johnston, who had suffered brain damage as a result of contracting meningitis as a baby, had been bleeding from her mouth during the night.

'Service pressures'

The nurse said she did not learn how many teeth Ms Johnston had had removed, what time she had the operation and was unaware of the type of anaesthetic she had undergone.

Asked by coroner David Reid, why she did not find this out, Ms Bennett replied: "Honestly, I don't know."

Ms Johnston failed to wake up that day, was bleeding from her mouth intermittently and was also "gurgling" as she breathed.

Diana Johnston, Rachel Johnston's mother, said she thought she was leaving her daughter "in safe hands" at the care home

Despite this, basic observations were not carried out and notes were not kept on Ms Johnston's condition.

"She had not come round in almost 24 hours... this was a possible aspiration situation with a very vulnerable person. Why not a phone call then?" Mr Reid asked Ms Bennett.

"I don't know," replied the nurse.

Ms Bennett called 111 that evening when she became concerned, but "service pressures" meant an out-of-hours nurse did not call back for 90 minutes, after Ms Bennett clocked off shift.

It was not until 14:00 the following day that Ms Johnston's oxygen saturation levels were found to be 63%, when normal levels are 95-100.

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"We dialled 999 straight away," said Ms Bennett, as they became aware Ms Johnston was "extremely unwell".

She died 10 days after her family agreed to turn her life support machine off.

The hearing continues.