An accumulation of errors in the commercial residential care center Het Beatrixhuis in Roosendaal has led to the 91-year-old resident Riet Goossens breaking her hip last year and eventually dying. This is apparent from a report by an independent committee of inquiry and conversations with relatives about which the KRO-NCRV research platform Pointer will publish on Friday.
“Els, you must come over, your mother has fallen and she is lying on the floor.” These are the penetrating words from a telephone conversation that have stayed with Els Meesters-Goossens from Roosendaal.
Her demented mother got out of bed on September 15, 2021 after an afternoon nap and suffered a big crash. The fall went unnoticed because the device that registers whether someone gets out of bed did not work. An employee had reported the defect with the motion sensor, but nothing was done about it.
“My mother was a sweet demented person. In 2017 she moved to Het Beatrixhuis. The first four years she never had anything. But a year ago she got complaints, medical things. And everything went wrong.” she tells research platform Pointer.
Els mentions some examples:
- an open wound to her mother’s leg was not immediately noticed,
- she was on blood thinners for a pacemaker,
- a broken fever thermometer was used.
Mother Reed was taken to hospital after the unfortunate fall on September 15, where she had surgery on her hip. Back at the nursing home, she deteriorated rapidly. In the final phase of her suffering, the GP no longer had confidence in the staff of Het Beatrixhuis. She therefore engaged an external hospice team to administer morphine. Riet died two weeks after the crash.
According to the investigation committee, the elderly woman could have been prevented from lying on the floor for a while. The motion sensor stopped sending signals for a month.
A report about this was insufficiently followed up, as a result of which the problem was not solved, writes the investigation committee. The care plan was also not adhered to. It stated that the woman had to be woken after a one-hour sleep so that she could go to the bathroom.
The Beatrixhuis is one of the many residential centers of the commercial care organization Daily Life. The research shows that the GP was not involved in the consultation with various departments of Daily Life. She was never even invited. This while the general practitioner is almost always the main practitioner at Daily Living.
Daily Life puts on the penitent for the incident in Roosendaal last year. “Yes, very sad story, where absolutely things did not go well for us. It’s human work, mistakes have been made and we are now working on improvements to prevent this in the future,” operations manager Bob Huiskamp told Pointer.
Staff at all 82 Daily Life locations in the Netherlands are now being trained in the use of motion sensors. There will also be a new procedure to ensure that GPs are involved in care consultations. This is stated in the action plan that accompanies the report. The Health Care Inspectorate says it has taken note of the report and sees no reason for further investigation.
“My mother was a cheerful person,” Els concludes, “she was always smiling. Sure, everyone dies at some point, but my mother was not yet at the point of death. That really came about because of this.”