Source · Prevention of Future Deaths

Philip Powell

Ref: 2017-0352 Date: 30 Nov 2017 Coroner: Zafar Siddique Area: Black Country Responses identified: 1 / 1 View PDF

Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Date 30 Nov 2017

56-day deadline 29 Jan 2018

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

View full coroner's concerns

1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound.

2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility.

Responses

1 respondent

Dudley Group NHS Trust NHS / Health Body

PDF

Action Taken

The Trust has equipped all District nurse bags with a box of Debrisoft and has held a meeting with the Debrisoft Rep to discuss the issues when raising a prescription through the GP surgery. The Debrisoft Rep is liaising with GP surgeries and local pharmacies in order to cascade educational advice regarding product and FP10. (AI summary)

View full response

Dear Mr Siddique,

Re: Response to Regulations 28 Report to Prevent Future Deaths – The late Mr Philip John Powell

I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 30 November 2017, in respect of the late Philip John Powell. I should extend again the condolences of the Trust to Mr Powell’s family.

The MATTERS OF CONCERN are as follows –

1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which may have helped in managing the wound.

In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility.

The important issues you raise have been taken very seriously within the Trust and I enclose an action plan which confirms: a) the actions taken by the Trust in response to your concerns: b) the target dates for completion of those actions; and c) the officers with responsibility for progress of the actions.

I trust the information provides assurances to you that the Trust has taken appropriate action to mitigate any further patient safety issues with regards to timely procurement and availability of this product in future.

Report sections

Investigation and inquest

On the 20 August 2017, I commenced an investigation into the death of Mr Philip John Powell. The investigation concluded at the end of the inquest on 30 November 2017.

The conclusion of the inquest was a short narrative conclusion of: Mr Powell Died after developing sepsis when a pressure sore became infected and deteriorated rapidly from a grade 3 to grade 4.

The cause of death was:

1a Sepsis and Bronchopneumonia 1b Infected Sacral Pressure Sore and Buttock Abscess

Circumstances of the death

i) Mr Powell was an 83 year old gentleman who had a medical history including Parkinson's disease, dementia and history of previous strokes. ii) He lived at home and was cared for by his family with support of Community nurses. iii) In July 2017 he started to develop an uncategorised stage 3 pressure ulcer and moisture lesion. iv) He was reviewed by a tissue viability nurse on the 18 July 2017 and Debrisoft which is anti-bacterial and used in the treatment of wounds wasn’t available at the time and the nurse placed a request for more supplies. v) No Debrisoft was in fact ordered. The pressure ulcer was then cleaned and dressed and managed with Flaminal Hydro and allevyn instead. vi) By the 4 August there were now clear signs of infection and the ulcer had become malodorous and inflamed. vii) By the 7 August the ulcer had deteriorated rapidly and he was admitted to Russells Hall Hospital where a 7cm cavity was identified and suspected

[IL1: PROTECT] sepsis. viii) Despite further treatment his condition continued to decline and sadly he died on the 16 August 2017 after developing sepsis and bronchopneumonia due to the infected pressure sore.

Action should be taken

Although an internal investigation was completed, it did not address the issue of the delays in ordering Debrisoft and you may consider it is important to revisit this area to look at the systems in place.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0352
Date of report: 30 November 2017
Coroner: Zafar Siddique
Coroner area: Black Country

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 Jan 2018.

Sent to

Dudley Group NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.