Pensioner's fatal foot ulcer 'could have been prevented', inquest hears
Thursday February 11, 2010
By JOSIE HINTON
A CARE home has been criticised by medical staff at the Royal Free Hospital for “excessive” delays in referring an elderly man who later died from an infected sore.
Jack Taylor, 88, a former hairdresser, died from sepsis – blood poisoning – in June last year at the Hampstead hospital after a pressure ulcer on his left foot became severely infected.
An inquest at St Pancras Coroner’s Court on Tuesday heard how Mr Taylor’s sore was seen numerous times by nursing staff and general practitioners at Ash Court Care Centre in Kentish Town, where he lived. But by the time he was seen by Royal Free nurses, the wound had become a “grade 4” sore, which commonly results in death.
Jemell Gherrety, a tissue viability nurse at the Royal Free, told the inquest she was “concerned” at the severity of the wound when Mr Taylor, a wheelchair user, was admitted. She said: “My concern was: why had this patient not been referred by his GP? I think a more aggressive referral should have been made, if you take into account his history. There would have been a point where this could have been prevented.”
The inquest heard that in April last year, nurses at the Ascham Street care home noted a “foul-smelling discharge” from Mr Taylor’s foot but a specialist was not called until two weeks later.
Olive Ramban, one of the nurses who cared for Mr Taylor, said: “As protocol we don’t refer immediately. I believe you can’t just heal a wound in a snap of a finger.”
Mr Taylor was not seen by a specialist for another ten days. When Samantha Grantham, a tissue viability nurse, saw him at the start of May, the wound had become a “grade 3.4” sore – meaning the depth of the wound could not be measured.
Ms Grantham, who works for NHS Islington but also covers Camden, arranged to visit him again two weeks later but by this time he had been taken to the Royal Free after becoming “drowsy and unwell”.
Recording a narrative verdict, coroner Dr Andrew Reid said Mr Taylor died from “chronic medical causes, the degree of which were recognised at a late stage”.
He added: “Mr Taylor died from sepsis due to or as a consequence of the grade 4 pressure ulcer on his left heel. I’m not persuaded to make a rule 43 recommendation [guidance to prevent future deaths] at this stage but should there be further concerns I will make the appropriate reports.”
Responding to criticism, Nancy Rasool, manager of Ash Court, said nothing more could have been done to save Mr Taylor. She added: “As far as we are aware we followed protocol. In Jack’s case we were looking at promoting comfort to the end of life.”
Mr Taylor’s wife of 53 years, Sheila, who lives in Dorman Way, Swiss Cottage, described her husband as “one of the greatest”. She said: “He was loved by everyone that knew him and was highly respected in his profession.” He worked for the Richard Henry salon in Knightsbridge and was hair stylist to models used by Vanity Fair.