A coroner has found that a famous historian died of a preventable bone infection after being placed in “terrible” home care after his failed discharge from the hospital.
When he was sent home from University College London Hospital (UCL) in January, Professor Richard Shannon was not provided with a special bed and mattress, despite the high risk of developing pressure sores.
Friends of the 90-year-old man who wrote a two-volume biography of William Gladstone gathered around to make sure he was well taken care of when he got home.
However, an investigation at St Pancras coroner’s court revealed that district nurses were not properly directing and monitoring her care, while an agency care worker had left the Professor in her own human waste.
Coroner Mary Hassell said she was shocked by the “horrible lack of humanity” when she concluded that Professor Shannon’s re-hospitalization on 13 January and subsequent death on 19 February could have been avoided.
“Had his skin integrity been properly monitored and treated appropriately, he would not have developed a pressure sore of this severity and would not have died,” he said.
“What struck me most throughout the investigation into Richard Shannon’s death was that many professionals were assigned to his care, many professionals went to his home, many professionals spoke to him, but still very basic elements of his needs were neglected.
“Despite all the resources wasted, it was not taken care of as a whole.”
The investigation found that Professor Shannon died of pneumonia, bone infection and infected ulcer.
When he was first discharged from UCL on January 5, with a nearly healed pressure sore. However, he was not provided with a pressure reducing mattress and mattress on which he could lie down at home.
“He was at greater risk of pressure ulcers and so it was a precaution to look for,” said the coroner.
Professor Shannon said she is sedentary and has diabetes, and that district nurses from Central London Community Healthcare are expected to check pressure sores at daily visits by the hospital to assist with insulin administration.
District nurses also waited for the caregivers to carry out the checks from the Kapital Care UK Limited agency maintained by the City of Westminster, but there was no evidence that the message had been delivered.
“When a district nurse came home the morning after she was discharged, she found that Professor Shannon’s catheter bag was so full and dislodged that it had blatantly and significantly soiled herself,” the coroner said in a report voicing concerns about the future deaths.
“He was in this condition when a Capital caregiver visited him that same morning, but the caregiver hadn’t cleaned him or changed the catheter bag.
“It took exactly three hours for the district nurse to take care of her patient’s needs. Caregivers from Capital were reserved by the City of Westminster to visit Professor Shannon’s home for one hour four times a day. One of his special duties was to take care of the personal hygiene needs of this old and vulnerable man, who was unable to take care of himself.
“The explanation for the capital keeper leaving him in this condition was that there was no soap or towels on the property. This excuse seemed to me to show a terrible lack of humanity, and I was shocked to hear it.
“Actually, Professor Shannon was clearly well-liked, and her friends had done everything they could to get her house ready for her, including stocking her bathroom with soap and towels that the district nurse found easily.
The coroner added that although Westminster Council conducted a post-mortem investigation, there was no evidence of a change in systems or education.
“Apparently the lesson has not been learned,” he said.
The report has been sent to UCL Hospitals NHS Trust, Central London Community Healthcare NHS Trust, Westminster Council and Capital Care.
A spokesperson for the Central London Community Healthcare NHS Trust said: “We take this opportunity to acknowledge and regret that communication regarding the care Professor Shannon has received has remained below the standards we expected.
“Following the investigation, we have already changed our discharge policy and will work closely with our healthcare and social care colleagues to ensure that shared care in the community meets the needs of our patients.”
A UCLH spokesperson “expressed our deepest condolences to Professor Shannon’s family and friends,” said: “We are working with community partners to ensure our discharge plans are well understood, and we are reviewing our processes to determine if more information and support can be provided at discharge patients. ”
A Westminster Council spokesperson said: “The Council wishes to extend our deepest condolences to the loved ones of Mr. Shannon, as the well-being of our residents is our priority. We’ve asked the Adult Protection Partnership Board to do a review of what’s going on and look at the actions of all relevant agencies.”