Inquest Finds Neglect By Leicester Nursing Home After Death Of Much-Loved Grandmother

Anna Ptackova
  • Anna Ptackova died aged 66 at Leicester General Hospital, while being cared for at Dane View Nursing Home in Leicester
  • An inquest into her death found ‘had it not been for the neglect of the home, Anna would not have died when she did’
  • The Coroner highlighted multiple failures in Anna’s care and risk management of a pressure sore amounting to a gross failure by the home
  • The family raised frequent concerns during the six months Anna was at Dane View regarding her specialised diet, hygiene and personal needs
  • Nelsons has been supporting Anna’s daughter to find answers

A Coroner has revealed her damning findings of a Leicester care home, concluding that neglect and gross failure had contributed to the death of a 66-year-old grandmother.

Anna Ptackova died as a result of sepsis that developed from a pressure sore while being cared for at Dane View Nursing Home in Leicester. She also had a diagnosis of Huntington’s disease since 2001 – a progressive neurological disease that led to her requiring 24/7 care – which was listed as a contributing factor in her death.

Following a three-day inquest at Leicester Coroner’s Court, the Coroner concluded on Friday 7 June that ‘had it not been for the neglect of the care home, Anna would not have died when she did’.

On 24 and 25 December 2022, Anna’s daughter Martina Hanouskova visited her mum for Christmas. Then on 26 December, she spent several hours trying to get through on the phone to Dane View to ask about taking her mum out to spend some time at home with her family for Christmas.

Eventually, she visited in person but was told by staff that she was not able to take her mum out due to the severity of a sacral ulcer – or pressure sore. This was the first time Martina had been made aware of this concern. She was told Anna required round the clock observations and bed rest, with regular repositioning every two hours to take the pressure off her wound. Martina was also told her mum would be checked for infection.

Martina made daily visits after this and then on 29 December, Anna had been moved to a different room, and Martina noted she had become very unwell and extremely dehydrated, and she raised her concerns to staff.

She was told to revisit on 3 January when her mum was seen by a tissue viability nurse. During this visit, the dressing was removed, and the nurse inspected the pressure sore. Despite being in extreme levels of pain and having a Paracetamol prescription for whenever needed, Anna was not given any pain relief.

Martina was told by the nurse that her mum would need to go to hospital due to suspected sepsis and an ambulance was called. Martina questioned why body charts were not completed and no one at Dane View had been monitoring food and fluids for her mum.

Anna was first taken to the Leicester Royal Infirmary and then transferred to Leicester General where she was treated with antibiotics for the sepsis, and intravenous fluids for dehydration. Martina was told by doctors that her mum was not well enough to undergo surgery, and the infection had likely spread to the bone.

Despite ongoing care, Anna sadly deteriorated and passed away on 20 January. The medical cause of death is as stated by the medical examiner as 1a: Sepsis; 1b: Grade 4 Sacral Ulcer; 1c: Huntington’s disease.

Throughout the inquest, evidence was presented from various people involved in Anna’s care, including her daughter Martina. Submissions were made to find neglect by Dane View, which were upheld by the Coroner in her final conclusion.

In arriving at her finding of neglect, the Coroner noted the following failures:

  • There was no initial or ongoing assessment of Anna’s pressure sore risk level. There was no effective communication of her condition between staff and to the Huntington’s disease (HD) team, the GP or tissue viability team.
  • There was no escalation to the HD team, the GP or the tissue viability team.
  • There is evidence that Anna’s repositioning did not happen two hourly.
  • There is evidence that the best mattress for Anna’s level of risk was provided, but not until 29 December 2022 after she developed the sore. The mattress should have been provided earlier.
  • Anna’s food and fluid requirements were not met, nor were they recorded such that they could inform other care.
  • The dressings on the pressure sore were not changed as they should have been, thus increasing the risk of sepsis which was the eventual cause of her death.
  • These failures cumulatively amounted to a gross failure and had they not occurred the outcome would have been different.

Martina had initially cared for Anna at her home, but a serious fall prompted her to seek 24/7 care for her mother. Anna spent time at three nursing homes between 2012 and 2020, including eight years in one facility – however, she had to move each time due to safeguarding issues.

In her witness statement, Martina shared how she had raised various concerns for the care at Dane View Nursing Home, including Anna’s special diet not being followed, Anna appearing unclean and staff not having the understanding of her illness to support her fully.

One of the most notable concerns that Martina flagged, was not being made aware of the pressure sore that would ultimately lead to her mum’s death.

Martina, on behalf of her family, said in a statement:

“Losing my beloved mum in this way has been extremely distressing and heart breaking for our family. While I was making frequent visits, and raising my concerns throughout mum’s care, hearing about the neglect and failures by Dane View has been so much worse than I could imagine.

“Providing or finding care for a loved one is so difficult; you put your trust in people to not only ensure your family is looked after, but that you will be kept informed if things change. This was not the case for mum or the rest of my family. Even though I visited multiple times, I was still unable to get the truth and there were many times I felt ignored. During the whole time mum was at Dane View, her care plan was not updated once, meaning they could not address her needs properly. This is meant to be carried out monthly, and weekly for more fragile people.

“It is so important we provide a voice for the vulnerable and ensure someone is speaking for them, when they cannot do it themselves. It is not enough to act when a safeguarding issue is reported – there must be regular checks and regular updates to families, and more people need to be aware of the risks to know when there is a serious problem. I hope lessons will be learned from this, and no one has to go through what we have experienced.

“Even when mum got her Huntington’s disease diagnosis, she put her faith in doctors, and it did not alter her positive outlook on life – she never complained and still enjoyed her favourite things. She was fun, loving and caring, enjoyed travelling and music and most of all, spending time with her family. Life was not always easy for mum, but she smiled every day, worked hard and did so much to keep us all happy. She has left us with memories that we will cherish forever.”

Matthew Olner, Partner in our Medical Negligence team, has been assisting Martina during the process. Matthew said:

“This ruling comes 18 months since Anna’s death, in what has been an incredibly difficult time for Martina and her family in their search for answers.

“The level of care for Anna fell far below what was expected, and what Anna deserved, and I commend Martina’s bravery in sitting through the inquest and having to share her experience in court.

“The inquest highlighted serious failings by Dane View Nursing Home, and indeed, that Anna’s death was as contributed to by neglect. While this brings little comfort to Martina and her family, this is an important finding that holds people accountable, and I hope to see changes made as a result.

“Martina has used her voice to speak up when her mum could not, and she has continued to do that throughout this process, and I hope she is now able to find some peace and remember happier times with her family and loved ones.”

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