Serious failings may have shortened mother’s life, Ombudsman finds

“Serious” failings in the care of an elderly woman at a Northern Ireland care home may have shortened her life, a watchdog has found.

Public Services Ombudsman Margaret Kelly said the failings in the treatment of the former resident at the Cottage Care Home in Coleraine were “preventable”.

Mrs Kelly received a complaint from the daughter of the late resident about two separate incidents at the care home which is owned by the Conway Group Healthcare.

The complainant considered the care her mother received was “seriously inadequate and totally unsatisfactory”.

She said in the first incident her mother sustained a fractured leg while being moved by staff, and in the second incident she claimed that poor oral health care led to a delay in finding her mother’s dentures lodged in her throat.

After a detailed investigation it was found that “not enough” care was taken while the resident was being helped to move from her bed to her chair and her foot became caught in a bedrail.

Despite the resident indicating pain, the report said a fracture injury was not detected until 24 hours later.

The Ombudsman report also said the resident’s dentures were “lodged in her throat for up to 24 hours undetected”.

“We found this was due to no oral health care plan as well as a failure to have a clear oral health care policy,” the report stated.

“The resident experienced swallowing and breathing difficulties, and we were critical that the home did not recognise sooner the possibility that these symptoms could be related to the resident’s dentures having become displaced.”

It added: “Noting evidence which linked poor oral hygiene with aspiration pneumonia in elderly people, we concluded that the incidents caused the resident to suffer a significant degree of pain and discomfort.

“We found on balance, that the home’s failings in the care and treatment of the resident were preventable, and that the incidents may well have contributed to the shortening of her life.”

The chief executive of Conway Group Healthcare has apologised to the late resident’s family following the outcome of the investigation.

Mrs Kelly said it was clear the late resident’s daughter and her two brothers were “devoted” to their mother and involved in decisions relating to her care.

“The trauma and distress of losing her in the circumstances reflected in this report was evident in their correspondence to the home and to my Office,” she said.

“I understand that this report will have made distressing reading and I recognise the emotional impact on a family in bringing a complaint of this nature forward.

“It is a testament to the love and devotion they had for their mother that they want to ensure no other family suffers a similar experience.”

As well as recommending the apology, the Ombudsman’s office asked the home to carry out staff training and service improvements in oral hygiene, and in the moving and handling of elderly residents.

Conway Group Healthcare accepted the Ombudsman’s recommendations.