Source · Prevention of Future Deaths
Royston Kemp
Ref: 2019-0148
Date: 2 May 2019
Coroner: Andrew Harris
Area: London Inner (South)
Responses identified: 0 / 1
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A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.
Date
2 May 2019
56-day deadline
23 Sep 2019 est.
Responses identified
0 of 1
Coroner's concerns
A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.
View full coroner's concerns
In the circumstances it is my statutory to report to YOu: May 20" Mr from from fracture The 26th, duty
A nurse working at Marlborough Court Care Home; who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants In so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature but took no action
2) She failed to establish the care assistant's concern or whether she had met the concern before or after her assessment
3) She failed to measure Vital
4) She failed to escalate to medical care Or refer; in the process failed to enable a diagnosis of fractured femur to be made
A nurse working at Marlborough Court Care Home; who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants In so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature but took no action
2) She failed to establish the care assistant's concern or whether she had met the concern before or after her assessment
3) She failed to measure Vital
4) She failed to escalate to medical care Or refer; in the process failed to enable a diagnosis of fractured femur to be made
Report sections
Investigation and inquest
On 30*k March 2016,I opened an investigation and on 26h March 2019 an inquest into the death of Mr Royston Kemp (008222016 MM), 85 years, who died at Queen Elizabeth Hospital on March 2016. The medical cause of death of Kemp's death was recorded as follows: la Pneumonia Aspiration Advanced Dementia II Fragility fracture of left hip operated. Infected venous ulcers Whilst the main cause of death was natural and he was at high risk his fragility, the immobility a traumatic was % key contributor to his death. circumstances that led to the fracture in the care home cannot be determined,
Circumstances of the death
Mr Kemp was an uncomplaining 85 year old suffering from dementia and with a history of fractures and falls who suffered an unwitnessed traumatic fracture of his left femur on or soon before 26th February 2016 in his care home. He injured his hand and elbow on 25th, had a bruise on his thigh on had a need for increased analgesia and a swollen leg on Z7th: He was examined by a nurse on 27th but not referred to hospital until 28th when a massive bruising was discovered. He was in a pOor state. Despite surgery on 29th and rehabilitation he died peacefully at 21.34 on 2Oth March from a chest infection and dementia_
Action should be taken
In my opinion action should be taken to prevent future deaths and [ believe you Fitness to Practice Nursing and Midwifery Council have the power to take such action. send this report to assist YOU with YOur assessmnent:
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Report details
- Reference
- 2019-0148
- Date of report
- 2 May 2019
- Coroner
- Andrew Harris
- Coroner area
- London Inner (South)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Sep 2019 (estimated).
Sent to
- Nursing and Midwifery Council