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Historian died after being exposed to ‘appalling’ home care

by Ozva Admin
Historian died after being exposed to ‘appalling’ home care
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The noted historian died of a preventable bone infection after being exposed to “appalling” home care following a failed hospital discharge, a coroner has found.

Professor Richard Shannon did not receive a special bed or mattress when he was sent home from University College London Hospital (UCL) in January, despite being at high risk of developing pressure ulcers.

Friends of the 90-year-old, author of a two-volume biography of William Gladstone, banded together to try to make sure he was well cared for when he returned home.

But an inquest at St Pancras Coroner’s Court found that district nurses had failed to adequately direct and supervise his care, while an agency worker had left the teacher lying in his own human waste.

Coroner Mary Hassell said she was shocked by the “appalling inhumanity”, concluding that Professor Shannon’s readmission to hospital on January 13, and subsequent death on February 19, could have been prevented.

“If the integrity of his skin had been properly monitored and he had received proper treatment, he would not have developed a pressure ulcer of that severity and would not have died,” he said.

“What struck me the most during the inquest into the death of Richard Shannon was that so many professionals took care of him, so many professionals attended his home, so many professionals met with him, but still very basic elements of his needs were left out. . .

“Despite all the resources expended, he was not cared for as a whole person.”

The inquest found that Professor Shannon died of pneumonia, a bone infection and an infected ulcer.

When he was first discharged from UCL on January 5, with a pressure ulcer that had almost healed. But they did not give him a bed to relieve pressure and a mattress to lie on at home.

“He was at risk of further pressure ulcers, so it was a measure that should have been pursued,” the coroner said.

She said Professor Shannon was immobile and suffering from diabetes, and the hospital expected Central London Community Healthcare district nurses to check for pressure ulcers at daily visits to help with insulin administration.

The district nurses, in turn, expected carers from the Kapital Care UK Limited agency, employed by Westminster City Council, to carry out the checks, but there was no evidence that the message had been passed on.

“When a district nurse arrived at the home the morning after discharge, she discovered that Professor Shannon’s catheter bag was so full that it had dislodged, and he had demonstrably and significantly soiled himself,” the coroner said, in a report. It raises concerns about the future. deceased.

“He was in this condition when a caretaker from Kapital had visited him earlier that morning, but the caretaker had not cleaned him or changed the catheter bag.

“It took the district nurse three hours to adequately attend to the needs of her patient. The City of Westminster had booked caretakers from Kapital to visit Professor Shannon’s home for an hour four times a day. One of his specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.

“The explanation of the Kapital caretaker for leaving him in these conditions was that there was no soap or towel in the property. This excuse seemed to me a demonstration of a terrible lack of humanity and I was surprised to hear it.

“In fact, Professor Shannon was obviously well-liked, and his friends had done everything they could to make his home ready for him, even stocking his bathroom with soap and towels that the district nurse easily found. Apparently, Kapital’s caretaker simply hadn’t opened the bathroom cabinet.”

The coroner added that although Westminster Council had conducted an inquest after the death, there was no evidence of a change in systems or training.

“Apparently, no lessons have been learned,” he said.

The report was sent to UCL Hospitals NHS Trust, Central London Community Healthcare NHS Trust, Westminster Council and Kapital Care.

A spokesman for the Central London Community Healthcare NHS Trust said: “We acknowledge that on this occasion, communication about the care Professor Shannon received fell short of the standards we would expect, and we regret this.

“After the investigation, we have already modified our discharge policy and will work closely with colleagues in health and social care to ensure that joint care in the community meets the needs of our patients.”

A UCLH spokesperson expressed “deepest condolences to Professor Shannon’s family and friends” and said: “We are working with community partners to ensure our discharge plans are well understood and we are reviewing our processes to determine whether can provide more information and support.” when discharging patients.

A Westminster Council spokesperson said: “The council would like to extend our deepest condolences to the loved ones of Mr Shannon, as the well-being of our residents is our top priority. We have asked the Board of the Association for the Protection of Adults to carry out a review of what happened and analyze the actions of all the agencies involved.

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