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Chrissy Dunnington is seen in a December 2017 family handout photo. Dunnington died in March 2018 after entering a Halifax hospital on Jan. 28 with a bedsore that had created a fist-sized hole that exposed her spine.Joanne Dunnington/The Canadian Press

A Nova Scotia inquiry has determined a woman who died seven weeks after entering a hospital with a bedsore did not receive adequate care, medical attention or “necessities of life” from her nursing home.

A Health Department investigation under the Protection for Persons in Care Regulations concluded a complaint about the care of Chrissy Dunnington was founded, according to a report recently sent to her family.

The 40-year-old woman died in March 2018 after entering a Halifax hospital on Jan. 28 with a bedsore that had created a fist-sized hole that exposed her spine.

The report’s findings say Parkstone Enhanced Care had clear guidelines on wound care for staff to follow, but there was “evidence that staff were not following those policies and procedures.”

It says there were “gaps” in the co-ordination of Dunnington’s care, in the documentation of her care and there were “limited consultations” with both internal health-care staff and outside specialists.

The findings also says Dunnington should have been repositioned in her bed or chair a minimum of once every two hours while awake and twice per night, but there wasn’t documentation this occurred.

The report says homes should follow an established risk-assessment tool on wounds, but there wasn’t any evidence this was done quarterly as required.

An e-mailed statement from the family says the report shows the level of care was substandard at the private home operated by Shannex.

The province’s chief medical examiner has determined the death was not a criminal matter, and police have said they have closed the case. However, Dunnington’s family says in the email it believes police should resume their investigation, based on the report’s findings.

“This matter cries out for evidence to be heard under oath and for witnesses to be cross-examined,” they wrote.

Parkstone Enhanced Care has said it completed a review of its practices and has brought in numerous changes, including improved wound care.

Catherine MacPherson, vice president of operations at Shannex, said in an e-mail, that the company is taking the report very seriously. “Now that we have the report, we have begun a detailed review to ensure that the actions associated with each directive are in place,” she said.

She said management at the company introduced a wound prevention plan in May 2018 that has resulted in improvements “in areas such as reporting and management of wounds, communication with residents and families, leadership and training, technology and accessing support from external experts.”

The Health Department has said long-term care facilities are now required to report the number of pressure injuries monthly, and that information is posted online.

Bedsores are caused by sustained pressure on certain parts of the body – typically at the tailbone, hips or heels – among some patients who are unable to move because of physical limitations or if they’ve been sedated with medication.

Dunnington suffered from the worst class of bedsore, Stage 4, which expose bone, muscle or tendons beneath broken skin.

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