NSW bed sore death could have been prevented: Coroner

By Dr. Ananya Mandal, MDAug 26 2010

After the death of a severely disabled woman in New South Wales, the coroner has ruled that the death due to bed sores was avoidable and caregivers need more training to manage such cases. 26-year-old Kate Therese Bugmy died at Broken Hill Base Hospital in June 2007 as a result of sepsis from bed sores. She had severe cerebral palsy, epilepsy and an intellectual disability and weighed just 36 kilos when she died.

The coroner, Mary Jerram, said that the death could have been prevented if her family had taken appropriate steps to help her get treatment and if her care was better resourced and co-coordinated. The coroner recommended that protocols need to be drawn up to deal with such cases and that awareness of the prevention and treatment of pressure sores be better promoted among nursing staff, patients and caregivers.

The coroner criticized the way Ms Bugmy was neglected by her depressed mother and pregnant sister and brought to notice that there were gaping holes in the State’s disability care system. Ms Bugmy did not have a lifter or hoist for moving in and out of bed or even a pressure-relieving mattress. Her family was not advised of the dangers of untreated bed sores, her weight was not monitored and no checks were made between her leaving relief care and her presentation at hospital, when she was unconscious and dying.

Ms Jerram said, “Why the [Department of Ageing, Disability and Home Care] closed Kate's file in 2002 [when she was 21] was never clarified to my satisfaction…The services available in far western NSW are dangerously strained…Had there been some co-ordination, ideally in the form of a case manager, between the various service providers … the risk may have been identified in time to prevent Kate's death.”

Ms Jerram was indignant saying, “Almost no one met their full duty of care to Kate while she was at home…If not, as her uncle said, failed by everybody, Kate Bugmy was failed by a fragmented, badly under-resourced, under-staffed and unco-ordinated system.”