Retired sales manager from West Bilney Robert Nuttall died after developing ‘likely avoidable’ infection during stay at King’s Lynn’s Queen Elizabeth Hospital
An 83-year-old man died after developing a serious infection while recovering from a broken pelvis in hospital, an inquest has heard.
Retired sales manager Robert Nuttall, of West Bilney, was taken from Delph House Care Home in Welney to Lynn’s Queen Elizabeth Hospital following a fall in early 2023.
Following his death at the QEH on March 5 – having developed MRSA – a serious investigation was carried out, with actions undertaken including audits and training.
The inquest, held at Norfolk Coroner’s Court last Friday, heard from Mr Nuttall’s son Alix Nuttall, who said, in a statement read to the court, that his father had suffered from Parkinson's disease for many years.
He said that, in the months before his death, Mr Nuttall began needing assistance with simple daily activities, and numerous falls led to hospital visits.
“He was spending more time at the hospital than at home,” Mr Nuttall Jnr said.
On his final visit to the hospital, it became “very apparent that the staff were very busy” and so things such as needing the toilet “became very stressful”.
“My mother tried to visit most days at a time when lunch was being served as he needed help with being fed,” he added.
“His health was slowly deteriorating and then he contracted MRSA. He got to a point when he couldn’t communicate, so he couldn’t tell us how he was feeling.”
Mr Nuttall Jnr said that they did not feel that his father had been mistreated but that “other patients took up more time”.
“My father was left on his own,” he said.
The inquest also heard from Sister Clara Simao, manager of the QEH’s Elm Ward – an emergency surgery ward.
She said, in a statement read to the court, that on February 7, the plan had been to mobilise Mr Nuttall and for him to be discharged back to a new care home once it was appropriate to do so.
On February 15, Mr Nuttall suffered another fall, but an x-ray found that there was no change to his injury.
In the next couple of weeks, the patient’s observations had deteriorated. It was thought that it was possible that he had hospital-acquired pneumonia and it was discovered that he had MRSA, so he was given intravenous antibiotics.
Sister Simao said: “It was noted that the patient had an open cannula which was a possible source of infection.”
Dr Deven Vaghela, locum consultant in Infectious Diseases and Microbiology at the QEH, said Mr Nuttall had been tested for MRSA upon arrival which returned a negative result.
His statement was also read to the court, which said: “It’s certainly possible that he acquired MRSA while an inpatient in hospital.
“The cannula could have been an entry site.”
Asked for more information by area coroner for Norfolk Samantha Goward, Dr Vaghela said: “The most common entry is from open wounds.
“On the balance of probabilities, there’s a good possibility that it was acquired in the hospital or the care home where prevalence is higher.”
An internal serious incident investigation was undertaken at the QEH following Mr Nuttall’s death there on March 5.
Sister Emily Hodges, the hopsital’s lead nurse for governance and surgery, said: “The documentation on the cannula was poor.
“The cannula found by the consultant didn’t have a sticker on it so it is not clear how long it was in place, making it a potential source of infection.”
She added that there had been a delay in discharging Mr Nuttall which led to an increased stay on Elm Ward – and he later developed the “likely avoidable” MRSA infection which contributed to his death.
The investigation had resulted in a number of recommendations and an action plan – with a “string of actions” taken.
These included multiple audits being carried out, as well as mandatory training for all staff on cannula care and the incident being shared at trust-wide meetings.
“Actions from review meetings also included deep cleans on the wards,” Sister Hodges added.
Summing up the evidence, Mrs Goward said: “It seems clear to me that, had Mr Nuttall not acquired MRSA, he was due to be discharged following the injury that he suffered in a fall.
“It seems to me, given the statements from the trust’s own serious investigation and the doctors say that it is most likely that he acquired MRSA while in hospital. It was a likely avoidable MRSA acquired while in hospital.”
She added that “a lot of work” had been done with the QEH’s nursing team in relation to audits in the time since his death.
“These do generally show an upward trend,” Mrs Goward said.
“I’m satisfied that the trust, having investigated, has taken action and there is no need for me to write a report to prevent future deaths.”
The inquest was told that Mr Nuttall's medical cause of death was given as infective endocarditis (the inflammation of the inner lining of the heart) and pneumonia, caused by MRSA.
Other significant contributing conditions included dementia, Parkinson’s disease, atrial fibrillation (a heart condition that causes an irregular heart rate) and frailty of old age.
Mrs Goward recorded a short narrative conclusion that Mr Nuttall died due to the consequences of hospital-acquired MRSA.
She offered her condolences to his loved ones.
