Disabled woman dies after nurses left blocked catheter in her causing severe infection and sepsis

A woman who was severely disabled died after staff at a nursing home left a blocked catheter in her, causing severe infection and sepsis.

Sandra Miller, who had Down’s Syndrome, Alzheimer’s disease, hypothyroidism and Type 2 diabetes, was in the care of staff at Mortimer House Nursing Home in Bristol after she was discharged from hospital in May 2015.

But an investigation has now found staff had not properly drained the catheter they put in her, causing complications with the infection.

She was re-admitted to hospital in June 15, 2016, when nurses found “foul-smelling, pus-like urine’” in the bladder, according to the report.

Ms Miller died six days later despite doctors’ best efforts, after suffering from a respiratory or a urinary tract infection and heart failure.

Despite her death, the area manager of the Milestones Trust, which ran the nursing home, told a court she “could not confirm” if anything was done to discontinue the procedure which led to Ms Miller’s death.

Avon Coroner’s Court has now ordered the trust to make improvements and changes.

What happened?

Ms Miller was being cared for here (Image: BristolLive)

Ms Miller was discharged from hospital to reside at Mortimer House Nursing Home in Kingswood, which is owned and managed by the Milestone Trust.

Because of her disabilities, she had problems with going to the toilet. She was fitted with a urinary catheter, and it was agreed with her in May 2015 she would be sedated when the catheter is being changed.

In September, a consultant urological surgeon was called because Ms Miller had become agitated and would try to remove the urine bag.

As a result, it had become practice at Mortimer House to remove the bag and tubing and allow the open catheter to drain freely onto a pad.

The consultant warned, in a letter to the GP and nursing home, that this practice of allowing an open catheter to drain was dangerous and could lead to infections.

He told nurses the practice should not be continued, and recommended the use of a flp-flow valve instead.

But the assistant home manager admitted to court the letter had not been seen by her colleagues or her, despite it being stamped as ‘received’ in October.

They continued to allow the urinary catheter to drain freely, tucking the open end of it into her incontinence pad, which she she wore because she had trouble controlling her faeces.

But that meant the catheter was close to or in contact with her excrement, which increased the risk of infection.

‘Pus-filled urine’

Mortimer House in Kingswood (Image: BristolLive)

On June 15, Ms Miller became unwell and she was rushed to Southmead Hospital after an out-of-hours doctor assessed that she might be suffering from sepsis because of pneumonia or a urinary tract infection.

“The staff nurse in the Emergency Department observed the catheter to not be connected to a bag nor was a spigot fitted,” the Prevention of Future Death report read.

“In evidence, the staff nurse stated the tip of the catheter was dirty.

“On removing the catheter, a large quantity of foul-smelling, pus-like urine drained from the bladder, suggesting the catheter had been blocked.

“Investigations revealed she was suffering from respiratory and a urinary tract infection and heart failure.

“She was treated for sepsis, and blood cultures later revealed she had an E-coli septicaemia.”

Doctors put Ms Miller on a course of antibiotics, but she deteriorated and died in hospital six days after she was admitted, on June 21.

Any lessons learned?

The Avon Coroners Court

The area manager of the Milestones Trust told the court at Ms Miller’s inquest she was unsure if any action had been taken to stop the practice of leaving a urinary catheter on free drainage, more than 18 months after Ms Miller died.

She also failed to explain if procedures had been implemented, and if staff received the necessary training.

Assistant Coroner Dr Peter Harrowing has now written to the Milestones Trust to order “urgent action” to ensure urinary catheters are not allowed to drain freely. Specialist advice should be sought if necessary and all relevant staff must be trained.

Jeff Parry, director of operations at Milestones Trust, said: “We would like to extend our sincere apologies to Sandra Miller’s family and to offer them our deepest condolences.

“Our staff were very fond of Sandra, who we supported for many years, and we share in the family’s loss. She was a unique woman and a joy to spend time with.

“We accept that we fell short of the standards our residents and their families should expect from us and we have taken on board all of the coroner’s concerns.

“As a result, we have made improvements to our policies and working practices.

“We have worked closely with other health professionals to minimise the risks associated with catheter care and we have put in place a comprehensive training programme for all our nurses and support workers who are involved in catheter care across the trust.”

Source: https://www.bristolpost.co.uk/news/bristol-news/disabled-woman-dies-after-nurses-1664411

 

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