Tetraplegic woman living in community care dies from sepsis caused by a necrotic pressure wound.

Inquest dates: 17 March 2016; 11 – 15 July 2016; 8 – 10 August 2016 (delivered 8 December 2016) Coroner:John Lock, Deputy State Coroner Place: Maroochydore Date of death: 10 October 2013

Case Summary

On 8 August 2012, Leah Elizabeth Floyd, aged 48, fell from a balcony at her home. As a result of the fall, Ms Floyd became a tetraplegic. She was hospitalised for a year at the Princess Alexandra Hospital (PAH). Ms Floyd was discharged from PAH on 26 August 2013 to an assisted living home on the Sunshine Coast run by BE Lifestyle.

As a result of her long term hospitalisation, Ms Floyd developed pressure area wounds, particularly on her elbows and sacrum. These were treated by PAH but had not completely resolved at the time of her discharge to BE Lifestyle. Blue Care provided an in-community nursing service to Ms Floyd for pressure wound care and management of her indwelling catheter.

On 5 September 2013, Ms Floyd was admitted to Nambour Hospital for treatment of mental health issues on the basis of an alleged suicide attempt involving her wheeling her chair into the path of a reversing car and comments being made by Ms Floyd about wanting to die.After Ms Floyd returned from the Nambour Hospital on 19 September 2013, her sacral wound deteriorated rapidly and her general health declined.

Ms Floyd passed away on 10 October 2013 from respiratory arrest secondary to sepsis following pulmonary and cutaneous infections.

Issues for Consideration

  • What was the cause of Ms Floyd’s death?
  • Was the treatment provided to Ms Floyd in supported accommodation at BE Lifestyle adequate and appropriate?
  • Did the Department of Disability Services appropriately respond to Ms Floyd’s concerns about BE Lifestyle?
  • Was the treatment provided to Ms Floyd in the Nambour Hospital adequate and appropriate?

Evidence & Investigations

Review of services provided by Disability Services

  • Disability services funded Ms Floyd so she could access accommodation support and services within the community.
  • Ms Floyd completed a formal complaint to Disability Services regarding her treatment at BE Lifestyle and as a result six service improvement recommendations were made by Disability Services and implemented suitably.
  • Disability Services investigated Ms Floyd’s complaint in a comprehensive manner, responded appropriately to her concerns and needs and when it became apparent that Ms Floyd had lost trust in the management of BE Lifestyle, Disability Services acted expeditiously to find alternative accommodation.

Review of care while at BE Lifestyle

  • Throughout the period that Ms Floyd was in the care of BE Lifestyle, Belinda Wardlaw (owner and director of BE Lifestyle) maintained that Ms Floyd had significant mental health issues and believed she did not have the capacity to make her own decisions, despite advice from the PAH and Nambour Hospital that she had full decision making capacity and no cognitive impairment.
  • BE Lifestyle had concerns about its capacity to provide care for Ms Floyd based on her perceived mental health issues.
  • The wound care provided to Ms Floyd by Blue Care and BE Lifestyle between 26 August 2013 and 5 September 2013 was adequate as there was no significant deterioration in Ms Floyd’s wounds. Blue Care also conducted an internal review of its services, which highlighted areas for improvement and which have been implemented.
  • Dr Sanders (Ms Floyd’s GP) referred Ms Floyd to Nambour Hospital mental health on the basis of Ms Wardlaw’s concerns on 5 September 2013. Dr Sanders failed to consult with her patient, Ms Floyd, prior to doing so. That was inappropriate and a misunderstanding of Dr Sander’s ethical duty to ensure patient confidentiality.
  • On Ms Floyd’s return from Nambour Hospital (on 19 September), Ms Wardlaw devised ten restrictions for Ms Floyd including rules such as ‘no visits from children’. The Disability Service considered those to be a breach of Ms Floyd’s human rights, a breach of the Disability Services Act 2006 and noted that BE Lifestyle did not have the legal capacity to impose those restrictions.
  • At the time of her return to BE Lifestyle on 19 September 2013, Ms Floyd had lost trust in the management provided by the centre.
  • Blue Care was not informed of Ms Floyd’s return to BE Lifestyle until 24 September (5 days after discharge). That gap in care had a significant impact on the deterioration of the wound.
  • Blue Care nurses, not BE Lifestyle staff, noticed that Ms Floyd’s pressure relieving mattress had deflated between 24 September 2013 and 27 September 2013. The sacral wound deteriorated significantly in this time and, had it not occurred, this may have changed the outcome.
  • There were occasions when Ms Floyd refused to be turned due to pain and she continued to smoke against advice. Ms Floyd also refused care from her GP and refused to go to the hospital.

Review of mental health assessment and support provided by Nambour Hospital

  • There were no serious concerns with the mental health assessment and support provided by the Nambour Hospital.
  • At the time of Ms Floyd’s psychiatric assessment, Dr Taumanova assessed that Ms Floyd did not have a significant psychiatric disorder requiring an in-patient stay in a mental health unit.
  • While there were deficiencies in the Hospital’s discharge summary, they were in relation to the documentation and not the planning of the discharge itself. The mental health assessment and treatment were otherwise adequate.

Review by Dr Buchanan of Clinical Forensic Medicine Unit of Nambour Hospital admission

  • Upon reviewing the available medical material, Dr Buchanan did not raise concerns with the care provided by the Nambour Hospital during her admission and up to her death.

Response by BE Lifestyle

  • BE Lifestyle have not been trained for wound care management – they are trained to “advise on the need for medical treatment and liaise with the client and providers such as Blue Care”.
  • It was agreed that the delay in getting the antibiotic prescription filled was a systemic failing, and their policy has changed to reflect this.

Findings

  • The cause of Ms Floyd’s death was sepsis caused by a necrotic sacral pressure wound. As a tetraplegic, she was particularly vulnerable to pressure sores.
  • In respect of the circumstances of Ms Floyd’s death, the coroner found that:
    • Ms Floyd was appropriately discharged from PAH and transitional arrangements were adequately put in place
    • The support program provided by the PAH Transitional Rehabilitation Program team to Ms Floyd was excellent;
    • Disability Services appropriately responded to Ms Floyd’s concerns and needs. BE Lifestyle was certified to provide services and care to a person with Ms Floyd’s complex needs. When it became apparent that Ms Floyd lost trust in the management of BE Lifestyle, Disability Services acted expeditiously to find alternative accommodation;
    • The overall decisions made and treatment given by Blue Care nurses was appropriate. It acknowledged that there could be improvements to documentation and some decision making that may have provided a better level of service. However, it could not be stated that there was any one decision or treatment option by Blue Care nurses which was causal to Ms Floyd’s death; and
    • BE Lifestyle did not have the skills to attend to Ms Floyd’s wound dressing (which was the responsibility of Blue Care). BE Lifestyle were generally able to provide for some of the other general cares, but there may have been some periods when Ms Floyd was not repositioned and the air mattress being deflated played more than a minor part.
    • Even if BE Lifestyle had the capacity to care for Ms Floyd’s physical needsit was not looking after some of her emotional needs. When Ms Floyd became unwell she was reluctant to be admitted to hospital largely due to her mistrust of BE Lifestyle and her GP.

Recommendations

  • BE Lifestyle is now in liquidation. The Coroner commented that, given the limited clinical governance framework evident at BE Lifestyle, he may have considered a recommendation that Disability Services consider auditing BE Lifestyle in relation to its compliance with the Human Service Quality Standards. Assuming that BE Lifestyle is not providing any more residential care services in Queensland, any such consideration is now unnecessary.
  • There were otherwise no recommendations directed to any other party.

Chronology of Events

28.08.2012
Leah Elizabeth Floyd, aged 47, is admitted to the Princess Alexandra Hospital (PAH) for injuries she suffered after falling from a balcony, which resulted in spinal fractures that caused tetraplegia. Surgery was performed to stabilize the fractures with a halo before she was admitted to the PAH Spinal Injury Unit (PAHSIU)
05.07.2013 Pressure areas developed on the sacrum (tailbone/base of spine).
25.07.2013 Grade 2 pressure area developed on the left buttock.
23.08.2013 Pressure areas on the elbows were noted as longstanding. The right elbow sore was oozing with mild cellulitis. Ms Floyd was prescribed an oral antibiotic for two weeks. PAH medical discharge summary was sent to BE Lifestyle and Dr Sander (GP).
26.08.2013 Discharged from PAHSIU into the care of BE Lifestyle.
27.08.2013 The full Transitional Rehabilitation Program (TRP) team, consisting of nurses, social workers, occupational therapists, physiotherapists and clinical psychologists visited Ms Floyd to discussed skin care management.
28.08.2013 BE Lifestyle staff allegedly heard Ms Floyd voice suicidal ideations.
31.08.2013 Incident with Ms Floyd’s wheelchair driving onto road. Treated by Ms Wardlaw as attempted suicide. Ms Floyd stated that her wheelchair had rolled inadvertently.
03.09.2013 Ms Floyd suffered a panic attack. Blue Care Nurse Joanne Martin attended. Her sacral wound was at stage 2, and the worst wound was on her elbow. Ms Floyd in good spirits and cooperative with treatment.
05.09.2013

TRP team visited Ms Floyd and noted that the wounds were improving.

Ms Wardlaw called Dr Sander expressing concerns about Ms Floyd’s behaviour. BE Lifestyle file notes indicate that Ms Floyd was having “constant suicidal ideation and expressing threats and the risk was considered to be high”. Dr Sander referred Ms Floyd to the Nambour Hospital. Ms Floyd was taken via QAS (with the assistance of the police) to the Nambour Hospital for psychiatric assessment and admitted involuntarily

06.09.2013

Nambour Hospital advised that they deemed Ms Floyd to be safe for discharge. BE Lifestyle refused to accept her return. Ms Floyd admitted to the Nambour Hospital on the basis that she would be discharged into supported accommodation shortly afterwards.

13.09.2013

Pressure sores were under control. Ms Floyd had an ongoing urinary tract infection and was seeking pain relief.

The Nambour Hospital contacted Ms Wardlaw to advise her that Ms Floyd was ready for discharge. Ms Wardlaw stated that they did not have staff with adequate mental health training to assist her.
18.09.2013 BE Lifestyle implemented ten restrictions.
19.09.2013

A teleconference was held between the Nambour Hospital, Disability Services, BE Lifestyle and members of the TRP. Blue Care was not invited to the meeting.

Ms Floyd was discharged from the Nambour Hospital and returned to the care of BE Lifestyle.
23.09.2013

Disability Services met with Ms Floyd to discuss her complaints regarding BE Lifestyle.

House Leader Andrea Messer redressed Ms Floyd’s sacrum wound, despite Blue Care attending the next day.
24.09.2013 Nurse from Blue Care attended. Ms Floyd had stage 2 pressure areas on her sacral area and both of her elbows. The wounds were all reviewed and their dressings attended to. Nurse noted that Ms Floyd’s pressure mattress was inflated.
27.09.2013

Nurse from Blue Care attended on Ms Floyd. The sacral wound was now large and necrotic, and Nurse graded this at 3/4. She also noted that the pressure relieving mattress was turned off.

Nurse recommended that Ms Floyd’s dressings be changed three times per week, and made a number of recommendations concerning the pressure mattress and other pressure sore management.
29.09.2013

BE Lifestyle noted that the dressing and pressure area were starting to weep and her IDC catheter was dislodged. The pressure areas had begun to smell. Ms Floyd was given incontinence pads. Ms Wardlaw called an ambulance for Ms Floyd but she refused to leave for fear that she wouldn’t be allowed to return.

30.09.2013 Ms Floyd’s condition deteriorated further. She continued to refuse to go to hospital.
01.10.2013

Ms Floyd was reviewed, but not examined, by Dr Sander. Dr Sander wrote a referral to Blue Care for catheter insertion, urine samples, wound swab and dressings, and gave Ms Floyd a prescription for antibiotics.

Blue Care attended to take swabs of the wounds, assess and dress the wounds and contacted TRP to reinsert the catheter.

02.10.2013

TRP attended Ms Floyd. She found Ms Floyd in bed with a saturated incontinence pad and urine saturating her sacral wound dressing. Reinserted a new catheter.

Blue Care attended to redress the wound, noting that it was at stage 4.
03.10.2013

Ms Floyd met with Disability Services to discuss her current wound, catheter and the support by BE Lifestyle.

Blue Care nurses attended and advised that Ms Floyd’s wound was showing signs of improvement.
04.10.2013 BE Lifestyle staff advised Ms Floyd that she needed to be hospitalised. She refused.
05.10.2013

Blue Care Nurse attended Ms Floyd. The dressing was contaminated with faecal matter but this had not entered the wound. She noted a small necrotic area but was unable to grade the wound beyond a 3/4.

Ms Floyd was very unwell overnight, but did not wish to be hospitalised.
06.10.2013

Ms Floyd stopped breathing at 3:00pm and staff performed CPR. An ambulance was called and she was admitted to the Nambour Hospital with a short history of low fever and intermittent coughing.

The sacral pressure wound was noted by hospital staff to have progressed from a “healing stage 2 ulcer (on 6 September 2013) to a 10cm x 8cm stage 3 ulcer with slough and necrotic tissue”. Ms Floyd also had bilateral heel and elbow ulcers (stage 2) and a urine infection.

The surgical team debrided the ulcers and found and drained an abscess. An MRI scan was performed which showed no signs of osteomyelitis.
07.10.2013

Episode of low blood pressure. At the time, the cause was unclear. Upon review, sepsis or autonomic dysreflexia are thought to be the cause.

A CTPA was performed, which showed no signs of pulmonary embolus. It showed evidence of a chronic right middle lobe collapse and moderate pericardial effusion.
09.10.2013 Reviewed by the infectious diseases team. The team noted that the sacral would was MRSA positive, her temperatures were fluctuating and she was acidotic.
10.10.2013 Began to develop respiratory failure secondary to sepsis. Ms Floyd was pronounced deceased at 0930 hours.
Autopsy revealed that the death was as a result of sepsis following pulmonary and cutaneous infections, the source of which was a necrotic sacral wound, Ms Floyd’s recent urinary tract infection and tetraplegia.