‘No gross failing’ at care home

INADEQUATE psychiatric assessment and poor communications between professionals contributed to the death of an elderly woman at an Oldham care home.

Elizabeth Murfin (91) died at Treelands Nursing Home, Fitton Hill, in September 2009.

Oldham coroner Simon Nelson gave a narrative verdict that both issues had influenced the prescribing of the strong painkiller fentanyl, which significantly contributed to her death.

The inquest had earlier heard the cause of death as fentanyl toxicity and aspiration pneumonia, with heart disease and other conditions all contributing.

On the last of a four-day inquest yesterday, Dr Mary Harrington, consultant geriatrician, said an appropriate change in medication for patients such as Mrs Murfin should be a move from a painkiller such as paracetamol to mid-range opiate — not a powerful opiate like fentanyl.

She said: “Where the patient is opiate-naive, it would be exceptional to consider a fentanyl patch.”

She said a discussion should have taken place between consultant psychiatrist Dr Michael Davies and the GP who prescribed fentanyl, Dr Robert Chisabingo.

Dr Davies told the inquiry he couldn’t recall claims by community psychiatric nurse Wendy Kettleton that he had given her specific advice on prescribing fentanyl.

In his summing up, Mr Nelson said he had been made aware of a number of areas of concern, including the variable quality of Treelands Nursing Home documentation, inadequacy of management, the induction, training and competence of Treelands staff and the home’s failure to fully involve the family. But he explained that addressing such areas was beyond his inquiry.

Mr Nelson said Dr Chisabingo had been misled by Mrs Kettleton’s misinterpretation of Dr Davies’ advice, and that the doctor had the best of intentions and was a particularly honest witness.

He said he didn’t believe staff at Treelands had been competent or adequately informed professionally to carry out the observations requested by the GP.

But he added: “I do not find any gross failing on the part of any individual in Mrs Murfin’s care, that led to or contributed to death.”

At the time, Treelands was run by care-home provider Southern Cross. The organisation ceased trading in October.


::Mrs Kettleton is not employed by the home, as previously, incorrectly, stated.