Mollie Bentham died at Rivington View Nursing Home; Albert Street, Horwich; Bolton on the 1s May 2015. On the 12th February 2015 Miss Bentham was admitted to the Royal Bolton Hospital, Bolton with lower respiratory tract infection and acute on chronic kidney disease: She suffered with confusion due to delirium and she had episodes of seizures: Following treatment at the Hospital Miss Bentham was transferred to Darley Court Intermediate Care Centre, Shepherd Cross Street; Bolton on the 6th March 2015 where she received further treatment; including treatment for Norovirus infection_ 3_ Prior to 23r April 2015 plans were being considered for Miss Bentham's discharge from Darley Court to a Nursing Home On the 23rd April 2015 the family of Miss Bentham had noticed that Miss Bentham was suffering with some abdominal pain and the family reported the abdominal to nursing staff at Darley Court However 27th the pain the concerns Of the family were not recorded in the nursing notes nor in the medical notes: The concerns were not brought to the attention of the medical team and no examination by the medical team was conducted in relation to the family concerns:
4. On the 24t April 2015 Miss Bentham had a medical review which showed that her CRP, which is a marker of infection, had risen to 178 and her white cell count; also sign of infection, had risen. There was a documented discussion with the family at 17.00 hours on the 24th April 2015 when the family, once again, mentioned the abdominal but the was not referred to in the documented note of the meeting: Prior to the meeting with the family at 17.00 hours on the 24th April 2015 Professor Baker , Consultant Geriatrician, had reviewed Miss Bentham at 10.30 hours on the same but the review by Professor Baker made no mention of abdominal pain and the previous concerns of abdominal pain mentioned by the family were not brought to the attention of Professor Baker , Miss Bentham was not sufficiently communicative to bring the to the attention of Professor Baker and the plan noted by Professor Baker at 10.30 hours on the 24th April 2015 did not refer to abdominal pain or any examination in relation thereto.
5. On the 26th April 2015 a Healthcare Assistant noted that Miss Bentham had a hard area to the left side of her abdomen and complained of The Healthcare Assistant informed the nursing staff of finding and Miss Bentham was given morphine sulphate in relation to the pain_ The 26t April 2015 was a Saturday and over the same weekend Miss Bentham was visited by two on call doctors, including an of hours General Practitioner but the doctors did not make a note of their attendance: A note was made in the nursing notes that the out of hours General Practitioner was called by the nursing staff as there was a hard mass to the left side of Miss Bentham's abdomen and her score had increased:
6. The Matron for Darley Court Intermediate Care Centre gave evidence that a doctor based at the Centre would be present at the Centre on a Monday to Friday from 9.OOam to 5.0Opm and on a Saturday and Sunday from 9.00am to 1.0Opm. Outside those hours a request for a medical review must be addressed to the out of hours GP service: The out of hours GP service will conduct an initial triage and a General Practitioner will attend subject to appropriate triage: 7 _ On the 27t April 2015, which was a Monday, Miss Bentham was reviewed by] who is a member of the medical team based at Darley Court Intermediate Care Centre; did not make a note of the attendance and there was no note that the attendance of the out of hours General Practitioner over the weekend and Miss Bentham's abdominal pain were brought to attention: 8, On the 27th April 2015 a Multi-Disciplinary Team Meeting was held and Miss Bentham was discussed at the Meeting_The note of the Meeting pain pain day pain pain. her out pain did not refer to those present at the Meeting nor in relation to any action to be taken or the persons to take any action: The note of the Multi-Disciplinary Team Meeting simply noted fast track paperwork and the fact that Miss Bentham had been accepted at Rivington View Nursing Home: 9_ On the 28th April 2015 a medical review identified that the abdomen was found to be tender but not in one specific place and the abdomen was described as soft, meaning no rigidity as would be expected with peritonitis; In view of the fact the patient had been constipated for some six days prior to the 28th April 2015 laxatives were prescribed as well as all previously prescribed medications:
10.On the April 2015 Miss Bentham was transferred to Rivington View Nursing Home, Albert Street; Horwich, Bolton where she deteriorated and died on the 1st