Peter James McBride died in February 2015, in the Royal Adelaide Hospital after being transferred from the Port Pirie Hospital where he had spent more than eight weeks waiting for a nursing home bed.
The 86-year old died of multi-organ failure due to sepsis which flowed from a pressure sore, with Coroner Mark Johns finding the nursing care for his condition to be “quite inadequate”.
“The evidence, in this case, demonstrated that the demographic exemplified by Mr McBride – the frail and elderly population – are the most common patient in regional hospitals such as Port Pirie,” Johns said in his finding on Friday.
“If they cannot manage pressure area care well, it is difficult to see why not. It should be their bread and butter.”
A former harness racing trainer, McBride was first admitted to the Port Pirie Hospital after suffering two falls on the same day at the home he had shared with his wife for more than 60 years.
He was managed essentially with bed rest in line with what staff thought was standard policy.
But Johns found that no such policy existed.
The bed rest led to McBride becoming immobile which, together with poor pressure care management, resulted in his sacral ulcer, or pressure sore.
In expert evidence, geriatrician Professor Craig Whitehead said while complications from a pressure sore were an unusual cause of death in older people, McBride did die from the “direct consequences of his pressure area”.
“Professor Whitehead said this is almost certainly a preventable death,” Johns said.
The Coroner was also critical of the insertion of a urinary catheter and the delay in providing the elderly patient with a special pressure mattress.
Johns said the Port Pirie Hospital had only four such mattresses and with two being used in the palliative care suite, only two were available for the rest of the hospital.
“Presumably the existing active pressure mattresses were already being used by patients in greater need than Mr McBride, difficult as it is to imagine a need greater than his,” he said.
“Clearly there is a need for a substantial increase in the number of active pressure mattresses at Port Pirie Hospital.”
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