Source · Prevention of Future Deaths
Derek Smith
Ref: 2018-0186
Date: 19 Jun 2018
Coroner: Andrew Haigh
Area: Staffordshire (South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted insufficient communication between the District Nursing team, family members, and carers, alongside issues with the availability of nursing records. This limited opportunities for timely interventions and decision-making regarding Mr Smith's treatment.
Date
19 Jun 2018
56-day deadline
2 Sep 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner noted insufficient communication between the District Nursing team, family members, and carers, alongside issues with the availability of nursing records. This limited opportunities for timely interventions and decision-making regarding Mr Smith's treatment.
View full coroner's concerns
In the circumstances it is statutory to report to you: It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly Iittle communication with the attending carers as well) . There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith's death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith's treatment. Suitable communication could well be significant factor in other cases. wonder if systems could be changed to ensure better communication between the duty my
District Nursing team, family members and other agencies involved.
District Nursing team, family members and other agencies involved.
Report sections
Investigation and inquest
On 29 December 2017 | commenced an investigation into the death of Derek Reginald Smith aged 86 years. The investigation concluded at the end of the inquest on 15 June 2018. The conclusion of the inquest was 'An elderly gentleman with major natural health problems who had developed severe pressure sores'
Circumstances of the death
Mr Smith lived at home but he could not manage any of his care needs and he was bedbound. He had regular attendances by carers_ He had frequent visits by district nurses and other professionals saw him at times. He died at his home on 21 December 2017 from aspiration pneumonia, On 6th December he had been found to have a pressure sore on his sacrum that went down to the bone_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Similar PFD reports
Report details
- Reference
- 2018-0186
- Date of report
- 19 June 2018
- Coroner
- Andrew Haigh
- Coroner area
- Staffordshire (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: 2 Sep 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Virgin Care Services Limited