Portsmouth care home where patient developed fatal pressure sore admits structural issues

An inquest resumed this week into the death of Pamela Ratsey after she developed a pressure sore that exposed her spine and became infected during her stay at Haven Care Home, Drayton, in 2017.

She was moved to Mary Rose Manor care home in 2018, where she died in March at the age of 81.

Debbie Embleton, who later took on the role of manager at Haven in December 2018, told Portsmouth Coroner’s Court that there were a number of problems when she started.

‘What I saw when I arrived was not appropriate,’ she said.

‘It was clear to me that processes and governance were not in place.’

Her evidence was echoed by CQC inspector Samantha Hart, who claimed co-owner Tess Hall had ‘gaps in her knowledge’.

Despite noting the pressure sore on Ms Ratsey the day before an inspection, Mrs Hall did not mention it, even when asked.

As she recalled challenging Mrs Hall on this, Ms Hart said: ‘She told me there ‘must have been some confusion’ when I challenged her on it.

‘I asked her to explain what happened and she said in 2017 they found a sore, but it healed.’

Evidence given prior to yesterday’s hearing questioned whether Ms Ratsey was being turned over enough, to relieve pressure on her sores, with ‘huge gaps’ in the paperwork.

The inquest heard how two cooks and two cleaners at the care home even doubled up as carers.

Paperwork also showed deputy manager Claire Smith was also called into action to aid Ms Ratsey on an almost daily basis.

When questioned by deputy coroner Lincoln Brookes on staffing issues, she said: ‘I can’t say that I helped once or 20 times, but as and when I was needed.

‘Clearly the other staff members were not available – they must have been busy elsewhere.’

Haven now has e-learning courses for all staff and an electronic log of all activities that take place, informing care plans for care home residents.

A final verdict will be issued by the coroner at a later date.