On 27th June 2016 commenced an investigation into the death of Ms. Sandra Miller age 55 years_ The investigation concluded at the end of the inquest on 24th January 2018. The conclusion was that the medical cause of death was Ia) Pneumonia; Il E. coli septicaemia to a urinary tract infection: Heart failure_ The conclusion as to the death was: The Deceased died of pneumonia contributed to by heart failure and E. coli septicaemia consequent upon a urinary tract infection. due

The deceased suffered with Down's syndrome, Alzheimer's disease, hypothyroidism, type Il diabetes mellitus and she had an epigastric hernia. She had impaired swallowing and on occasion suffered with aspiration pneumonia. In May 2015 she was discharged from hospital to reside at Mortimer House Nursing Home, Bristol, which is owned and managed by the Milestone Trust On discharge hospital she had a urinary catheter due to a voiding dysfunction_ This voiding dysfunction was considered to be related to her neurological condition; She was also incontinent of faeces. At a Best Interests Meeting held on 2Oth August 2015 it was determined that owing to Ms_ Miller becoming distressed and agitated at the time When her urinary catheter was changed it was agreed that she could be sedated for this procedure. Removal of the catheter was considered but when removed on previous occasions she had gone into urinary retention. Therefore it was planned to refer her to the urologist for further advice. She was seen on 1Sth September 2015 byl Consultant Urological Surgeon _ Ms_ Miller would become agitated and try to remove or at the urine As a resultit had become practice at Mortimer House to remove the and tubing and allow the open catheter to drain freely on to a In his letter of 30th September 2015 to the GP and copied to Mortimer House hoted that this practice meant that there was an open system from the outside world to the bladder which would increase her risk of infections and that this practice should not be continued He recommended the use of a flip-flow valve if a could not be used and if that was not successful to consider a suprapubic catheter: The GP in evidence stated that the GP records indicate the advice given to the staff at the home was to try the flip-flow valve A copy of this letter was date stamped as being received at Mortimer House on 15th_ October 2015_ However;, in evidence the Assistant Home Manager stated that letter had notbeen seen by her or her colleagues and therefore the recommendations of were not acted upon_ Consequently the practice of leaving the urinary catheter on free drainage continued, In evidence the Assistant Home Manager further stated that Ms_ Miller, who was incontinent of faeces wore incontinence pads, and the open end of the catheter was "tucked inside' this incontinent pad and the changed four times daily_ Therefore the open end of the catheter was in contact with , or close to, any faeces. On 15th June 2016 Ms. Miller became unwell and she was attended urgently by an Emergency Care Practitioner from the out-of-hours GP service He assessed her as suffering with sepsis probably due to pneumonia or possibly a urinary tract infection; Ms. Miller was admitted as an emergency by ambulance to Southmead Hospital, Bristol. The Staff Nurse in Emergency Department observed the catheter to not be_ connected to a nor was a spigot fitted. In evidence the Staff Nurse stated the tip of the catheter was dirty _ On removing the catheter a large quantity of foul smelling; pus-like urine drained from the bladder suggesting the catheter had been blocked. Investigations revealed she was suffering with a respiratory and / or a urinary tract infection and heart failure. She was treated for sepsis and blood cultures later revealed she had an E.coli septicaemia Notwithstanding appropriate antibiotic therapy Ms Miller's condition declined and she died in hospital on Zist June 2016. The primary cause of her death was considered to be pneumonia_ At the Inquest the Area Manager of Milestones Trust, a registered nurse, who conducted review in advance of the Inquest could not confirm that action had been taken to stop from bag pull bag pad. bag pad the bag this practice of leaving a urinary catheter to free drainage; that proper procedures had been implemented, and that staff had received any necessary training:

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: