Inquest: Hospital failures left brain damaged patient with severe wound

Graeme Irvine, senior coroner for east London, included the sore as a secondary cause of death on Ike Aigbe’s death certificate.

The death triggered an internal investigation at Queen’s Hospital, which uncovered several failings.

After becoming largely immobile and incontinent following a brain injury, making him prone to bedsores, Mr Aigbe was sometimes left sitting in the same position for up to six hours, an inquest heard last week.

Mr Irvine said this “would have left him in a position where, potentially, he was either soiling or wetting himself”.

Deputy chief medical officer at Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Justin Daniels, has offered condolences to Mr Aigbe's family, apologised he "didn't consistently receive the high quality of care he was entitled to", and said the trust is "determined to learn lessons".

The East London Coroner’s Court heard Mr Aigbe’s death had led to a series of changes at Queen’s.

But Mr Irvine said he might still raise formal concerns about future patient safety.

Cardiac arrest

Mr Aigbe, 53, from St Anns in Barking, was rushed to King George Hospital in Ilford in March 2021 after a major blood clot on his lungs sent him into cardiac arrest.

He was left brain damaged by a lack of oxygen and was moved to Queen’s for neurological rehabilitation.

He remained in hospital for the following ten months where, despite other improvements, his brain continued to shrink.

He developed a number of bedsores - or pressure ulcers - on his lower back and buttocks.

By November, one was so severe that it was rated a Category Four – meaning a wound potentially as deep as the muscle or the bone.

Mr Aigbe’s partner Jane Kaita said she had repeatedly raised concerns.

“I kept saying, ‘it’s graduating, it’s graduating’, and it ended up as a Category Four,” she told the court.

“It wouldn’t have ended up there if they had listened to me.”

Cause of death

On January 4, Mr Aigbe went into cardiac arrest and could not be resuscitated.

BHRUT said his death was due to sepsis after a urinary tract infection (UTI) caused by prolonged hospitalisation.

It did not mention the pressure ulcer.

When the family disputed this, Mr Irvine ordered an independent post-mortem.

Pathologist Dr Ali Al-Hakim agreed Mr Aigbe had died from sepsis, but said it was caused by pneumonia as well as the UTI, each caused by prolonged hospitalisation.

He also listed an “advanced pressure ulcer” as a secondary – meaning possible, but not proven – cause.

This saw BHRUT order an investigation into the case.

Failings

The investigation found gaps in Mr Aigbe’s records suggest he was left sat in the same position for up to six hours, in contravention of his care plan.

Although he was given a specialist dressing for his Category Four sore by skin viability nurses, regular nurses did not know how to replace it, the court was told.

It heard if the dressing came off, it often remained off until specialists could visit.

The investigation also found when nurses were changing dressings on bedsores, there was sometimes no evidence they were assessing the sores for improvement or deterioration.

But senior sister Hayley Osborne, who wrote the investigation report, testified she was “satisfied” all problems had since been fixed.

She said staff had been retrained, including in the use of specialist dressings, and patient notes were now checked daily to ensure staff were following their care plans.

Ms Osborne said a new system also required staff to photograph bedsores several times per week and upload the images, so changes were tracked.

Coroner Graeme Irvine told the East London Coroner's Court - temporarily housed at Barking Adult College - that he would defer his decision on whether to file a Prevention of Future Deaths report about BHRUT (Image: Archant)

Conclusion

Mr Irvine adopted Dr Al-Hakim's cause of death, saying he could not find it proved that the bedsore had contributed to Mr Aigbe’s death.

“I know that the family are probably never going to agree with me on that point, but that’s my ruling,” he said.

But he did keep it as a secondary cause on Mr Aigbe’s death certificate.

A lawyer for BHRUT asked Mr Irvine not to issue a Prevention of Future Deaths report, saying the trust had already "identified the appropriate areas of learning" and "mitigated the risks".

But Mr Irvine deferred his decision, pending written arguments from BHRUT and Mr Aigbe’s family.

Mr Daniels offered the trust's condolences to Mr Aigbe's family.

"We’re sorry he didn't consistently receive the high quality of care he was entitled to," he said.

"We are determined to learn lessons and have introduced a number of changes."