Source · Prevention of Future Deaths

Stanley Cummins

Ref: 2024-0119 Date: 4 Mar 2024 Coroner: Janine Richards Area: County Durham and Darlington Responses identified: 1 / 1 View PDF

Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.

Date 4 Mar 2024

56-day deadline 29 Apr 2024 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.

View full coroner's concerns

During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.

I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals.

The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed.

Responses

1 respondent

County Durham and Darlington NHS / Health Body

18 Apr 2024 PDF

Action Taken

County Durham and Darlington NHS Foundation Trust has implemented a 72-hour reassessment for patients admitted to care homes, updated wound assessments and care plans in SystmOne to include photography and off-loading advice, and booked study days for community nursing teams. They have also commenced work with suppliers to source a choice of heel off-loading devices. (AI summary)

View full response

Dear Mrs. Richards, Re: Mr. Stanley Cummins We are writing in response to your request for the Trust to take action in relation to the lack of comprehensive evidence provided to you at inquest that lessons had been learnt in relation to the accepted failings in the care of Mr Cummins, and in particular:
- the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or
- to escalate these issues as needed to other services and professionals to prevent future deaths, which you issued to County Durham & Darlington NHS Foundation Trust following Mr. Cummins inquest held on March 1st, 2024. The Trust would like to offer, its sincere condolences to Mr. Cummins’ family for their loss. We take very seriously the concerns which you have raised and have provided a detailed response below along with an action plan with clear timeframes (Appendix A). An action has been taken to ensure that nurses complete a visit and reassessment for patients admitted to care homes for intermediate care within 72 hours of their admission. This is part of the Urgent Community Response (UCR) criteria. This will facilitate the District Nurses to be involved in MDT care around nursing needs as a high majority of these beds in hours are commissioned in residential care and therefore this patient group may not have identified nursing needs before admission to a care home. All intermediate care patients will now be admitted through Community Crisis process requiring an assessment by a nurse before admission, and a new care plan will be launched when a patient is admitted to a care home for a nurse review within 72 hours. This will identify any input or recommendations. The wound assessments and care plans in SystmOne are being reviewed and updated to include photography and advice re: off-loading and onward referrals. Study days have been booked for key staff in all community nursing teams for June 27th and 28th 2024. This will include the launch of the updated assessments and care plans, equipment updates, incident reporting updates and the use of heel off-loading.

The new wound assessments have been coded to facilitate audit. The audit will be completed twice a year, commencing November 2024 (allowing time for the new process time to be embedded) and will include a number of specific wound types for example heel pressure ulcers and appropriateness of plans of care. Work has commenced with both equipment suppliers and Podiatry to source a choice of heel off-loading devices as currently there is only the option of one choice of heel off-loading device. Patient/carer information leaflets are also being developed regarding off-loading. We trust that the measures already implemented and those planned are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.

Report sections

Investigation and inquest

On the 16th of September 2022 an investigation into the death of Stanley Cummins, aged 84, was commenced . The investigation concluded at the end of the inquest on 1st of March 2024. The conclusion of the inquest was a narrative conclusion as follows:-

Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis. The pressure ulcer was caused as a result of the deceased sitting for long periods of time in a chair and pushing his heel onto the floor in an attempt to reposition, as he was in discomfort from damage which he had also sustained to his bottom. The pressure damage occurred in his care home between the 18th of July and the 2nd of August 2022, where he had been admitted for rehabilitation.

The ulcer was an avoidable injury with appropriate care and management of the known high risk of pressure damage.

Despite pressure damage being noted to the deceased including to his buttocks and legs there were no comprehensive changes to his care regime, to reduce the risks of further damage occurring, or to manage the pressure damage that had already been caused, becoming worse. There was no referral to the District Nursing team or other professionals for further advice in relation to pressure damage.

If the skin had been appropriately monitored it is likely that the early effects of pressure damage to the heel would have also been identified, at which point pressure relief and offloading should have been provided.

Once the deceased returned home and the pressure damage to the left heel was identified, no offloading advice or recommendations were given to family and carers from the nursing team responsible for his care, and it is likely that despite the deceased's other risk factors for pressure damage and for delayed healing of such, that with appropriate advice and care, namely complete offloading, amongst other measures, that further deterioration and evolution of the wound, would have been avoided.

The deceased died of sepsis, the underlying cause of this was the pressure sore to the left heel which developed into a necrotic ulcer. The wound was preventable with appropriate care and further deterioration of the wound was also preventable.

The death was contributed to by neglect.

Circumstances of the death

Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022 where he had been discharged on a palliative basis. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis.

Inquest conclusion

-

Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis. The pressure ulcer was caused as a result of the deceased sitting for long periods of time in a chair and pushing his heel onto the floor in an attempt to reposition, as he was in discomfort from damage which he had also sustained to his bottom. The pressure damage occurred in his care home between the 18th of July and the 2nd of August 2022, where he had been admitted for rehabilitation.

The ulcer was an avoidable injury with appropriate care and management of the known high risk of pressure damage.

Despite pressure damage being noted to the deceased including to his buttocks and legs there were no comprehensive changes to his care regime, to reduce the risks of further damage occurring, or to manage the pressure damage that had already been caused, becoming worse. There was no referral to the District Nursing team or other professionals for further advice in relation to pressure damage.

If the skin had been appropriately monitored it is likely that the early effects of pressure damage to the heel would have also been identified, at which point pressure relief and offloading should have been provided.

Once the deceased returned home and the pressure damage to the left heel was identified, no offloading advice or recommendations were given to family and carers from the nursing team responsible for his care, and it is likely that despite the deceased's other risk factors for pressure damage and for delayed healing of such, that with appropriate advice and care, namely complete offloading, amongst other measures, that further deterioration and evolution of the wound, would have been avoided.

The deceased died of sepsis, the underlying cause of this was the pressure sore to the left heel which developed into a necrotic ulcer. The wound was preventable with appropriate care and further deterioration of the wound was also preventable.

The death was contributed to by neglect.

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Report details

Reference: 2024-0119
Date of report: 4 March 2024
Coroner: Janine Richards
Coroner area: County Durham and Darlington

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Apr 2024 (estimated).

Sent to

County Durham and Darlington NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.