THE death of a pensioner with mobility and communication problems at a Blidworth care home is to be referred to a care watchdog.
Lorna Dallison died on 8th January after falling and suffering a head injury, an inquest into her death was told.
Staff at Churchfields Care Centre, on Churchfield Drive, failed to notify a GP or emergency services when Mrs Dallison (83) suffered a head injury after falling from her chair and told her family ‘it was just a scratch. She has been patched up’.
The grandmother-of-six had suffered a subdural haematoma and was admitted to King’s Mill Hospital after the fall on 4th January, but a CT scan showed nothing could be done for her and she died a few days later.
Maureen Rawson, a senior registered nurse and agency worker at Churchfields, said Mrs Dallison had slipped from the toilet on the day she was taken to hospital but she had not complained of any pain.
The nurse did not call for an ambulance as she said a GP was due to visit anyway.
She did not mention the head injury which Mrs Dallison had suffered falling from her chair a few days earlier on 1st January as she assumed the visiting GP already knew about it, the inquest was told.
Nottinghamshire coroner Stephanie Haskey asked Mrs Rawson if she was aware of an accident log started on 1st January which recommended hourly checks on Mrs Dallison.
She replied: “I was not aware I had to fill one in and did not know if the home had one. I checked for bruising and swelling but did not fill the form in and went up at least every half hour to check on her.”
Mrs Rawson said she told night staff Mrs Dallison had fallen and should be observed during the shift hand over.
Care assistant Lynn McIntyre, a permanent night worker at the home, said she had been informed of the fall but was given no instruction about observations. But, the normal procedure in such cases was to carry out ‘half hour obs (observations)’.
The care assistant told the hearing she started her shift at 8pm and, despite the fall, did not ask why she was not advised to observe the pensioner. She found Mrs Dallison in her room pale and unresponsive at 9.15pm. An ambulance was then called.
Mrs McIntyre was working the night of 1st January when the elderly resident had suffered a head injury, but could not explain why observations were not recorded after 7.20pm that day.
Tracey Henson, a senior registered nurse and manager of the home, said when a head injury was suffered, company guidelines advised staff to ensure patients were seen by a GP or emergency services.
If the injury was not a head trauma, residents were monitored for 12-24 hour periods.
She was not on duty on 1st January and could not explain why a doctor was not called after the fall or why observations were abandoned after 7.20pm.
The care home manager said Mrs Dallison’s family should also have been properly informed of what had happened.
She confirmed carers had no training on the delayed effects of head injuries but staff nurses should know and no instruction or training was given to agency workers on how records were kept.
She said processes at the Southern Cross care home had now been changed, but documentation should be improved and hand overs, more detailed.
Dr Clare Wilson, Mrs Dallison’s GP, said the elderly lady had been taking medication which makes people more prone to bleeds after head trauma and staff should have contacted herself or an ambulance when she had her first fall.
She confirmed that no mention was made of the fall when she examined Mrs Dallison for haemorrhoids on the day of her death.
“A subdural bleed can be a minor bump on the head and not make itself apparent for several days or weeks. It could have happened on the 1st or the 4th,” she said.
In recording a verdict of accidental death, Miss Haskey said: “We cannot know whether if different action was taken by the home she (Mrs Dallison) would have been taken to hospital on the 1st or if the outcome would have been any different.
But she added: “Full assessment of the risk she was in was not taken by staff on duty and full monitoring did not happen.”
Kit Hall, group manager for adult services for Newark and Bassetlaw, said there were issues relating to the use of agency staff and homes all had different processes but, it was their responsibility to make sure there was enough information.
She added; “I will pass this on to the CQC (Care Quality Commission) and the service director of my own department.”
Speaking after the inquest, Mrs Dallison’s daughter, Angela Cornell, of Rainworth, said: “She was a really outgoing person and loved dancing before she had a stroke but when she could not walk that was it.
“Dad has also died since - he just stopped eating and gave up.”
Ms Cornell said she would not be taking action against the home.