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Neglect contributed to disabled woman's teeth removal death

A disabled woman whose brain was starved of oxygen after an operation to remove all her teeth would probably have survived if care home staff had acted sooner, an inquest heard.

Staff at Pirton Grange Care Home, near Worcester, failed to spot Rachel Johnston, who suffered brain damage as a result of contracting meningitis as a baby, was developing hypoxia.

Miss Johnston, 49, fell ill shortly after being discharged from Kidderminster Hospital where all her teeth had been removed due to severe decay on 26 October 2018.

For the next 42 hours, Miss Johnston bled from her mouth intermittently, was heard "gurgling" and never fully woke up.

Despite this, care home nurses repeatedly failed to recognise she was dangerously ill, did not carry out basic observations or make notes on her condition.

By the time an ambulance was called two days after Miss Johnston left hospital, her "entire brain had been starved of oxygen", Dr Christopher Danbury told the inquest.

Readings showed her oxygen levels were 63% when a normal reading is 95-100% and she had suffered aspiration pneumonia.

Dr Danbury, who reviewed her care, said Miss Johnston had no chance of survival by the time she was taken to hospital but "probably would have survived" if taken to hospital the previous evening when staff called 111 for advice.

Senior West Midlands coroner, David Reid, said "gross failures" by two care home nurses to record and properly monitor Miss Johnston's condition contributed to her death.

He said: "These were basic medical checks that should have been carried out at regular intervals."  Without them it was impossible to build a picture of Miss Johnston's health after surgery.

He said the actions of Sheeba George and Gillian Bennett were "so serious - so total and complete, so patently not simple errors they can be described only as gross failures."

Mr Reid said 111 call handler, Alison Trueman, failed to ask direct questions when nursing staff called, but recognised she was working in stressful circumstances and had attempted to do what was best.

Miss Johnston had lived at Pirton Grange since 2013 so she could access medical care.

Her mother said: "When she needed it, they failed her and she died. What happens time and again to the families of people with learning difficulties is that we get sidelined by medical professionals, even when we clearly know the person involved best and love them the most.

"That is incredibly difficult to bear and no words can describe the agony of experiencing that."

Pirton Grange said it expressed "sincere sympathy and condolences" to Miss Johnston's family and friends.

The home added: "The care and wellbeing of our residents is paramount, and Pirton Grange accepts the finding of HM Coroner and recognise that there are lessons to be learnt by staff and management, as a result of Rachel's tragic death.

“Changes have been made within the organisation to implement improved systems and procedures. In addition, staff training has been undertaken in all the key areas highlighted by this sad case."