A nursing home has accepted there were “several considerable failings” in the care of a 98-year-old woman who died last year after developing a back sore.
Veronica Ayres was a resident at the Sonas Innis Ree Nursing Home in Ballyleague, Co Roscommon, from January 2023 to March 2024.
She died in Portiuncula University Hospital on March 9th and a complaint to the nursing home was subsequently made by her family regarding the care she received.
No individual or organisation has been held at fault.
RM Block
An inquest into the death of Ms Ayres opened in Gort, Co Galway, on Tuesday.
Pathologist Dr Suzanne Schneider explained Mrs Ayres died due to acute cardiorespiratory failure, due to acute suppurative pericarditis in the context of a stage-four pressure ulcer with abscess.
Originally from Ballinaheglish, Co Roscommon, Ms Ayres had settled in Liverpool for 66 years before returning to Ireland in 2007.
She moved to Innis Ree in 2022, where her family visited her regularly from the UK.
Her daughter, Christine McGowan, said her mother experienced repeated bed sores at the nursing home, and it was only at her insistence that a new cushion, suitable to relieve the bed sore, was bought.
She said no preventive measures were carried out during her mother’s residency. During her final visit on March 4th, 2024, she found her mother in a semiconscious state in her chair, mumbling “Help me, help me” and appeared to be in a lot of pain.
“We were told she was on strong medication,” Mrs McGowan said. The following evening, she was shown photos of her mother’s pressure sore.
“Only at this point was I informed about the pressure sore,” she said, adding that it had grown from 2cm to 18cm and was incapable of healing.
“We were completely shocked,” she said and insisted an ambulance be called immediately. At Portiuncula, her mother was “screaming in pain”. MS McGowan said she was told in the hospital that with earlier intervention the outcome may have been better.
“At the very least the pain management would have been much more successful,” she said.
Guy Walton, a nurse at the Sonas Group, investigated the complaint. He said of four main areas of concern, three were partially upheld and one was upheld.
The investigation resulted in a number of recommendations, including mentorship for nursing staff on pain assessment tools anda review of residents’ pain management. Improved communication with families was also put in place. The measures had resulted in improved wound management at Innis Ree, the inquest heard.
“Some of the findings of the report, particularly around palliative pain relief and wound care, have been shared across all the Sonas Nursing Homes so that their residents may also benefit,” Mr Walton said.
“Whilst no member of staff at Innis Ree was ever deliberately malicious towards Vera – who was in fact a well-liked and respected resident – we at Sonas have accepted that there were several considerable failings in Vera’s care which we deeply regret and we would like to thank Vera’s daughter Mrs McGowan for advocating in her mother’s memory to ensure the same mistakes do not happen again in the future.”
Dr Joyce gave a narrative verdict of death from sepsis arising from a large pressure ulcer on the deceased’s back. He said while efforts were made by staff at the nursing home to treat the wound, it continued to deteriorate.
“No individual or organisation is held to be at fault,” Dr Joyce said, and set out a number of recommendations on care improvements.
