Source · Prevention of Future Deaths
June Evans
Ref: 2017-0302
Date: 19 Oct 2017
Coroner: Caroline Topping
Area: Surrey
Responses identified: 0 / 1
View PDF
Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.
Date
19 Oct 2017
56-day deadline
14 Dec 2017
Responses identified
0 of 1
Coroner's concerns
Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.
View full coroner's concerns
1. The evidence showed that failure to refer the hospital acquired grade 3 pressure sore to the tissue viability nurse on the 8th June 2016 was as a result of the employment of an agency nurse who was unfamiliar with the Trust’s Policy on the Prevention of Pressure Sores. If the referral had been made to the tissue viability nurse on the 8th June 2016 it would not have deteriorated as it did.
2. The treating clinicians were unaware that Mrs Evans had developed a grade 3 hospital acquired pressure sore, noted on the 8th June 2016, until the 15th June 2016. They were therefore unable to make informed decisions as to her treatment, including the antibiotic regime to be followed.
3. Dietician’s advice in respect of the quantity of nutrition required by Mrs Evans was not implemented by the nursing staff. Naso-gastric feeding was advised by both the treating doctor and the dietician on the 14th June 2016. This advice was not followed and there was no evidence of why this did not occur. Mrs Evans was not provided with adequate nutrition.
4. Mrs Evans was nursed on 3 wards from the 4th to the 30th June. The wards were not staffed according to the levels identified as correct staffing levels by the hospital which detracted from the ability of the nursing staff to undertake the tasks required to protect Mrs Evans from pressure sores and ensure she received adequate nourishment.
5.
2. The treating clinicians were unaware that Mrs Evans had developed a grade 3 hospital acquired pressure sore, noted on the 8th June 2016, until the 15th June 2016. They were therefore unable to make informed decisions as to her treatment, including the antibiotic regime to be followed.
3. Dietician’s advice in respect of the quantity of nutrition required by Mrs Evans was not implemented by the nursing staff. Naso-gastric feeding was advised by both the treating doctor and the dietician on the 14th June 2016. This advice was not followed and there was no evidence of why this did not occur. Mrs Evans was not provided with adequate nutrition.
4. Mrs Evans was nursed on 3 wards from the 4th to the 30th June. The wards were not staffed according to the levels identified as correct staffing levels by the hospital which detracted from the ability of the nursing staff to undertake the tasks required to protect Mrs Evans from pressure sores and ensure she received adequate nourishment.
5.
Report sections
Investigation and inquest
An inquest into the death of Mrs June Evelyn Evans was opened on 11th July 2016 and resumed on 28th September 2017. It was concluded on 5th October 2017. I concluded that Mrs June Evelyn Evans died on the 1st July 2016 at St Peter’s Hospital, Guildford Road, Chertsey, Surrey and that the medical cause of her death was; 1a Sepsis 1b Sacral Ulceration I concluded with natural causes contributed to by neglect.
Circumstances of the death
Mrs Evans was admitted to St Peter’s Hospital on the 3rd June 2016. The presenting complaint was of diarrhoea. A Waterlow assessment score was recorded on admission of 23. This meant that Mrs Evans was at high risk of developing pressure sores. The Ashford and St Peter’s Trust’s Policy on the Prevention of Pressure Sores was not adhered to. Mrs Evans was not turned with sufficient frequency, her wounds were not observed as they should have been and she was not nursed on a pressure relieving mattress.
On the 8th June 2016 an agency nurse noted in the nursing records on a body map that Mrs Evans had developed a grade 3 hospital acquired pressure sore. The Trust policy required an immediate referral be made to the tissue viability nurse. Despite the pressure sore continuing to be recorded on the 10th, 11th and 12th June 2016 a referral to the tissue viability nurse was not made until the 13th June 2016.
Mrs Evans was seen on ward rounds daily between the 8th and 15th June 2016. During that period Mrs Evan’s inflammatory markers were rising and the treating doctors were trying to establish the source of the infection. Mrs Evans was started on antibiotics on the 12th June 2016. It was not until the 15th June 2016 that the treating doctors record the presence of the pressure sore and query whether this could be the source of the infection.
Mrs Evans was assessed by dieticians on a number of occasions during her admission to hospital and advice was given as to her nutritional requirements. A sufficient intake of nutrition is required to combat sepsis and repair damaged skin. Mrs Evans was not fed in accordance with the dietician’s advice and did not receive adequate nutrition.
The pressure sore deteriorated and became infected. At post mortem the pressure sore was found to measure 11cm by 14 cm and to be the full thickness of the skin. In addition the ulcer ran under the skin into the tissue for a further 5cm. Mrs Evans died of sepsis as the infection in the pressure sore on the 1st July 2016.
On the 8th June 2016 an agency nurse noted in the nursing records on a body map that Mrs Evans had developed a grade 3 hospital acquired pressure sore. The Trust policy required an immediate referral be made to the tissue viability nurse. Despite the pressure sore continuing to be recorded on the 10th, 11th and 12th June 2016 a referral to the tissue viability nurse was not made until the 13th June 2016.
Mrs Evans was seen on ward rounds daily between the 8th and 15th June 2016. During that period Mrs Evan’s inflammatory markers were rising and the treating doctors were trying to establish the source of the infection. Mrs Evans was started on antibiotics on the 12th June 2016. It was not until the 15th June 2016 that the treating doctors record the presence of the pressure sore and query whether this could be the source of the infection.
Mrs Evans was assessed by dieticians on a number of occasions during her admission to hospital and advice was given as to her nutritional requirements. A sufficient intake of nutrition is required to combat sepsis and repair damaged skin. Mrs Evans was not fed in accordance with the dietician’s advice and did not receive adequate nutrition.
The pressure sore deteriorated and became infected. At post mortem the pressure sore was found to measure 11cm by 14 cm and to be the full thickness of the skin. In addition the ulcer ran under the skin into the tissue for a further 5cm. Mrs Evans died of sepsis as the infection in the pressure sore on the 1st July 2016.
Similar PFD reports
Related inquiry recommendations
Scottish Hospitals Inquiry
IPC role specifications and staffing levels
Muckamore Abbey Inquiry
Risk-based inspection prediction
Muckamore Abbey Inquiry
AHP and social care workforce recruitment
Infected Blood Inquiry
Transfusion Laboratory Staffing
Infected Blood Inquiry
Training in Transfusion Medicine
Mid Staffs Inquiry
Safe staff numbers and skills
Waterhouse Inquiry
Ensure foster carers receive continuing support and access to specialist services
Fennell Inquiry
Ensure adequate staffing by suitably trained personnel in station operations rooms
Scottish Hospitals Inquiry
Training for IPC professionals engineers and clinicians
Southport Inquiry
Autism spectrum disorder police training
Report details
- Reference
- 2017-0302
- Date of report
- 19 October 2017
- Coroner
- Caroline Topping
- Coroner area
- Surrey
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: 14 Dec 2017.
Sent to
- St Peter’s Hospital