Gran’s death: the failings revealed

Reporter: Richard Hooton
Date online: 24 June 2010

36 hours before given treatment :: ‘Deficiency’ in recording food intake

A SENIOR doctor admitted a grandmother’s death may have been avoided if a hospital had acted sooner to ensure she was properly fed.

An inquest at Oldham magistrates court yesterday heard that Shirley Finan (71), of Incline Road, Hollinwood, died from multi-organ failure resulting from a clostridium difficile (C diff) infection.

But her family uncovered failings in her care at the Royal Oldham Hospital and are now considering whether to take action over neglect, saying she died because of malnutrition.

Consultant Dr Samuel Solomon admitted that food charts had not been recorded properly and more could have been done to get the retired warehouse operative to eat.

Mrs Finan was admitted on August 7 last year with cellulitis, a skin infection, and treated with antibiotics before being released a week later.

She was readmitted on September 2 with stomach problems and tests revealed the next day she had a C-diff infection. But it was 36 hours before she was given treatment.

She was hardly eating or drinking and two unsuccessful attempts were made on September 22 to insert a tube into her stomach to feed her. She worsened and died on September 25.

But her family say she did not appear well enough to be initially discharged from hospital and was still suffering from diarrhoea, a sign of C diff, and had told a nurse.

Daughter Beverley Finan, from Failsworth, said her mum wasn’t eating as she was celiac, requiring a gluten-free diet, but the hospital could not accommodate her needs.

She was also scared to eat as staff were not prompt in getting her to the toilet. She had also fallen on several occasions, including badly gashing her head.

Dr Solomon accepted her point that staff should have told them their mum was not eating so they could have intervened.

He said she had been discharged as observations two days before showed she was mobile and there were no problems and no record of her having diarrhoea.

Dr Solomon accepted treatment should have started earlier but said the delay did not contribute to her death. Nurses had tried to encourage her to eat and drink but could not force her.

He said: “I wholly understand there has been a deficiency in the recording of your mum’s food intake and if we had acted earlier then the outcome could have been different.”

But he could not say if she would have been saved.

He said he would take up with nurses the importance of food charts being properly kept and interventions put in place.

He said: “Your mother was very ill and we did the best we could to treat her medical problems, unfortunately we were unsuccessful.”

Coroner Simon Nelson said he was grateful for the unusual tenacity of the family.

He said they had raised two matters; That it’s important that someone on a specific diet is catered for and that inadequate record keeping had contributed towards deficiencies in care and it was crucial the hospital dealt with the problem. He said if there had been evidence of a link between the failings and the death he would have given a verdict of neglect.

Instead, he recorded a narrative verdict, saying death was by “reason of recognised complications of necessary therapeutic intervention.