Ashfield woman died after care home error

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AN Ashfield woman who died in a care home in the area was given drugs she was allergic to and forced to travel around 100 miles in a taxi despite being nursed in bed, an inquiry has found.

The 55-year-old, known as Adult C, was transferred from a home in Merseyside in 2008 to one in Ashfield before her death seven months later.

A Nottinghamshire coroner recorded a verdict of death by natural causes in the case but heard evidence of deficiencies in the care provided for her.

Now an independent serious case review, commissioned by Nottinghamshire Safeguarding Adults Board (NSAB), has found there was a lack of communication between the Liverpool home and the Ashfield facility.

It read: “Adult C was assessed by a manager prior to transfer but no member of staff from the receiving care home was involved with this assessment.”

The report found no record of attempts to seek advice from medical experts about the woman’s condition and whether the move would make it worse.

The report states: “Adult C was normally nursed in bed only occasionally sitting in a chair.

“Considering the length of the journey and the known vulnerability of Adult C’s pressure areas, the chosen mode of transportation was, at the very least, potentially harmful.”

The report tells how, once the woman was placed in the Ashfield home, her care needs were not addressed properly due to poor communication between staff and visiting professionals.

Staff tried to get her specialist help through the Tissue Viability Service, but treatment advice was not recorded and her health deteriorated.

Before her final admission to hospital, Adult C was prescribed penicillin by a GP who had already been given a report which told of her allergy to the drug. The GP was unable to explain the error.

After considering the woman’s case, NSAB recommended:

Better sharing of information between all organisations involved.

Making the care of residents the responsibility of a GP practice.

Putting early warning systems in place to recognise health deterioration.

Local authorities should consider the suitability of transportation when transferring vulnerable adults.

Said Allan Breeton, NSAB independent chairman: “We have analysed each of these cases in detail and now have a series of recommendations for a number of agencies. We believe these will help to protect vulnerable adults in Nottinghamshire.”