Fatal Accident Inquiry into the death of Jamesina MacKenzie


Miss Jamesina MacKenzie, born 2 October 1922, formerly resident at Wyvis House Care Home, Station Road, Dingwall, Ross-shire died on 31 May 2009 at Invergordon County Community Hospital, Invergordon, Ross-shire.

From 11 December 2008 until her final admission to hospital on 2 May 2009, and subsequent death in hospital, Wyvis Care Home was Miss MacKenzie’s place of residence.

A Fatal Accident Inquiry has found that her death was due to multiple pressure ulcers which she developed while resident at Wyvis House and terminally complicated by bronchopneumonia. 

The following are reasonable precautions which, if taken, might have avoided the death:

  • The complete and accurate recording, from the moment the wounds were first observed, of a wound assessment chart, a wound care plan, a daily record of the application of dressings and treatments and the monitoring and recording of routine physiological observations such as blood pressure, temperature etc. and the turning of Miss MacKenzie by the care staff employed at Wyvis House. 
  • The exercise of proper leadership and supervision by the management at Wyvis House to ensure that care was not only being given but was properly documented and to ensure that Miss MacKenzie’s condition was being adequately monitored and that significant deteriorations were promptly noted and reported.
  • It would have been a reasonable precaution for the General Practitioner to have asked to see and for the Care Home staff to have volunteered the information documented in the daily support plan notes kept by Wyvis House staff in respect of Miss MacKenzie, as this would clearly have drawn the attention of the Medical Practice to the history, duration and progression of the pressure ulcers.
  • It would have been a reasonable precaution for the General Practitioner to examine Miss MacKenzie’s pressure ulcers on a regular, i.e. at least weekly, basis between 8 and 22 May 2009, since such examination would have made the deterioration in their condition obvious and would in all likelihood have led to a decision being made to admit her to hospital for treatment which might have prevented the death.

In terms of section 6(1)(e), the following facts are relevant to the circumstances of the death: 

The circumstances of inadequate care and recording of the level of care given to Miss MacKenzie occurred in the context of a change of ownership of Wyvis House Care Home where the obligation on the new owners and management was to maintain or improve the quality of care to individuals

Against the background of Miss MacKenzie suffering a the progression of a significant illness in the form of pressure ulcers, while living in a care home setting, it is appropriate in the future for the Social Care and Social Work Inspectorate Scotland in the course of their fulfilment of their statutory duties of inspection and regulation of care homes to have regard to the level of medical and nursing expertise (whether internal to the care home or available externally) available to the care home and to include in their inspection regime an audit of the necessary record keeping.

In all the circumstances the Sheriff concluded that a reasonable precaution which might have avoided the death was the complete and accurate record keeping by Wyvis House nursing staff.  Had that been done, then the deterioration of Miss MacKenzie’s position would have been clearly noted and appropriate action taken more timeously than it was.

“The knowledge that this combination of circumstances was allowed to occur will, I hope, enable care homes and general medical practices, to identify similar factors at an earlier stage and allow measures to be taken to prevent the recurrence of such a situation being allowed to develop”. 

 Sheriff Macfadyen

Read the full Determination here