A woman in Reading with Multiple Sclerosis died after care providers failed to bring her specialist equipment when she moved to a care home, a new report has revealed.

The 63-year-old lady died of sepsis and pressure sores in 2019 after care home staff failed to ensure she had necessary equipment to manage her posture and relieve pressure.

Failures by Reading Borough Council (RBC) and an undisclosed Reading care home have been revealed in the Berkshire West Safeguarding Adults Review published this month.

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The woman’s name has been anonymised and she is known only as P in the report.

Her family, whose response to the findings is contained in the report, said the services meant to protect her, had failed her.

They said the “ghastly” contractures P suffered gave her “extraordinary pain” and resulted in pressure sores. The sores then led to sepsis and her family said the death would not have happened if she had been given appropriate care .

The family added: “Without both of these problems P would likely still be in her chair, getting out with her family, watching The Chase, and in her own inimitable way shouting at her sons.”

While the family had called for a full coroner’s inquiry  last year, the review says the coroner’s office has accepted reassurance from RBC that its enquiry has been resolved to the family’s satisfaction.

A spokesman for RBC said: “We are saddened by the unfortunate death of P and our sympathies are with her family following their loss.”

“There were many professionals and organisations involved in P’s care. We know everyone involved tried their best to assist her over a difficult period of declining health and struggles with independence. Issues were raised and there were areas which could have been improved to ensure a more consistent response to her care.”

A spokesman for the Berkshire West Clinical Commissioning Group (BWCCG) said: “We acknowledge and recognise the impact and learning from this review and have been proactive in addressing the issues, supported by our commissioned Integrated Care Home Support Service.”

What happened?

P, who had Multiple Sclerosis, developed contractures in both of her legs which resulted in multiple pressure ulcers due to her positioning.

  • What is a contracture? A contracture occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity. Contracture symptoms include pain and loss of movement in the joint.

She had been given equipment to manage her posture and relieve pressure, including a Toto lateral turning system, when she lived independently with support from carers but these had not always been used consistently.

When P moved into a nursing home, nobody realised she had specialist equipment and the equipment was not moved with her, while most staff were not aware of what contractures are and the importance of good positioning.

Her pressure sores got worse and became infected, resulting in sepsis, from which she passed away with in hospital.

What are pressure ulcers/sores and what is sepsis? Pressure sores are injuries to the skin and underlying tissue, which can reach the bone, primarily caused by prolonged pressure. Sepsis is a life-threatening reaction to an infection. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs.

What were the failures?

As well as the failure to move specialist equipment, the review found many professionals and care staff were unaware of what a contracture was and/or the intervention that could be provided and there was also no service available for residents with contractures at the care home.

Gaps were found in management oversight and adherence to Berkshire-wide agreed inter-agency adult safeguarding protocols.

This included lack of notifications of concern, delayed and incomplete safeguarding enquiries, missed care calls, missed follow-ups, lack of communication with family, poor recordkeeping, unclear decision-making and absence of clear risk-management.

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The review, written by Claire Crawley, also found the difficulty RBC had recruiting social care staff was one of the reasons for the failures.

Lessons learned

The council has fully accepted the findings of the review and says it has since developed and implemented a clear action plan to address the issues.

While the CCG has implemented changes including postural management initiatives and raising awareness of contractures in care homes.