Ex-policeman Victor Ashcroft died in agony after failures in his treatment at Wilmington Manor Nursing Home: Inquest
00:01, 15 June 2013
The family of a former policeman who died in agony are considering legal action after a coroner ruled he had suffered neglect and failures in his treatment.
Victor Ashcroft, 72, of Maryfield Close, Dartford, was a resident at Wilmington Manor Nursing Home, after been discharged from Darent Valley Hospital.
An inquest heard how a catalogue of failings had led to his death.
He had suffered bed sores and wounds had become infected.
Coroner Roger Hatch blamed the “failing” and “neglect” of medical staff at a nursing home for the death of Mr Ashcroft.
The inquest heard he had returned to the Wilmington Manor Nursing Home where he was a patient after having part of his right leg amputated.
His condition deteriorated as he developed severe bed sores on three patches over his legs and feet.
Ann Moore, a BUPA quality consultant, discovered a catalogue of shortcomings when she visited the home in Common Lane over two days in April last year.
Mrs Moore told the inquest that Mr Ashcroft, who was diabetic and bed-bound, had “complex needs”.
She said his pain and wound assessment charts were not consistently completed and signed off and his family had not been informed.
When she returned for a third day to examine Mr Ashcroft at the BUPA-run home, she noticed “an odour present usually indicating infection”.
She said: “All his wounds appeared to be infected.”
North West Kent coroner Roger Hatch said : “It seems very clear that you have found a number of failings.
“You are saying dressings should have been changed every third day, yet there is no evidence on paperwork you saw that had been carried out.”
Mr Ashcroft was admitted to Darent Valley Hospital in January, last year, for the amputation and was discharged back to the home on February 1.
When asked why Mr Ashcroft’s worsening condition had not been referred to the GP, deputy manager Cecilia Chunga said the doctor had told her he was not a qualified tissue nurse.
Staff nurse Sandesh Holkar said he had dressed Mr Ashcroft’s wounds several times.
On one occasion he told the hearing that he updated the care plan on the same day, yet in a written statement he said he had forgotten to do so.
Mr Hatch stopped the initial inquest after it came to light that his carers had been disciplined.
“The treatment was well below the standard demanded, in my view" - Coroner Roger Hatch
Describing it as “unfortunate” that he knew nothing of the action against the three employees, he said he wanted to see a written report on the matter before resuming.
Mr Ashcroft was re-admitted to Darent Valley where he died on April 19, last year.
A post mortem examination showed he died from pneumonia, hypertension, renal failure and haemorrhage.
Mr Hatch said : “The treatment was well below the standard demanded, in my view.
“I record as the cause of death the failing and/or neglect of medical treatment he received at the home.”
Son Phil said after the hearing: “The findings in the quality care report, supported by the coroner, were damning.
“After surviving complex brain surgery in 2010 with his renowned sense of humour intact, we are disappointed that he was failed at the end by a nursing team that genuinely appeared to have a good-humoured rapport with him.”
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