The death of a much-loved father-of-14 in the Royal Blackburn Hospital has led to changes that will hopefully save others in the future.
Mr James Redmond died aged 87 on January 3rd, 2013, from bronchial pneumonia, after he had had suffered a fall outside his home in Eastern Avenue, Burnley, the previous November.
The retired bus driver, who moved to Burnley from Ireland in 1945, underwent hip surgery on November 30th at the Royal Blackburn Hospital.
A full-day inquest in Burnley found that some aspects of his care “were open to criticism” as East Lancashire Coroner Mr Richard Taylor delivered a narrative conclusion.
But the coroner said that he welcomed changes that the East Lancashire Hospitals NHS Trust had brought in as a result of Mr Redmond’s death.
The inquest heard that Mr Redmond had broken the neck of his femur and was suffering from delirium and vascular dementia, which medical practioner Dr Raymond Hyatt described as “the most severe I have ever seen.”
Following surgery, Mr Redmond’s delirium became worse, and he sometimes refused to take medication to treat it. However, his family were unhappy that more steps were not taken to ensure he got the medication, and were also concerned at the quality of medical records.
One of his sons, also called James, said: “The notes on my father’s record said he was occasionally violent and awkward when it came to taking fluids and medication, but basic nursing care should have got past that. The plan to manage his agitation was diazepam. His notes say out of a possible 18 doses it was given just twice. This was preventing everything else from happening.”
Dr Hyatt said that options such as sedation and physical restraint were very risky and seldom used today.
Mr Redmond also experienced problems with constipation and his oral hygiene was not properly looked after.
This was supported by Matron Leanne Robinson, who undertook an independent assessment, and found faults with some record taking.
She said: “The documentation of fluids was poorly presented, and Mr Redmond’s weight was not obtained until December 23rd.
“Supplements were not well documented and food assessments were not always completed.”
Mrs Robinson accepted that care planning had not been very good and that the Trust was bringing in a generic care plan across the whole organisation as a result.
She added that there were a lot of new staff on Ward B22 at the time, but that staff numbers had now increased.
Expert witness Mrs Irene Waters, a specialist community public health nurse, said that management of delirium was very important and that there should have been an assessment by someone with a mental health background.
She said: “Without the correct mental health assessment, the care plan is fatally flawed. His mental condition was detrimental to his physical healing. However, his lack of mobility, asthma and a chest infection made him high risk.”
Speaking after the conclusion, Mr Redmond’s family said: “Our dad left behind many things of which we are proud, but this may be his greatest legacy.
“His dying has improved the chances of other people facing the same predicament because Royal Blackburn Hospital has now made these changes. We are very encouraged by that.”