Source · Prevention of Future Deaths

Jean McHale

Ref: 2016-0456 Date: 15 Dec 2016 Coroner: Thomas Osborne Area: Bedfordshire and Luton Responses identified: 1 / 2 View PDF

Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability Nurses in healthcare.

Date 15 Dec 2016
56-day deadline 9 Apr 2017 est.
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability Nurses in healthcare.
View full coroner's concerns
_ (1) That if pressure ulcers are not treated appropriately then the elderly in the community will suffer, develop Osteomyelitis leading to Sepsis and death_ (2) That there are not enough Tissue Viability Nurses working in the community or in the hospital to meet the needs of patients (3) An urgent review is necessary.

Responses

1 respondent
SEPT NHS / Health Body
30 Jan 2017 PDF
Action Taken

SEPT reports a service review has been undertaken, clear pathways are in place, and the provision of TVNs has increased. In addition community nurses have ongoing training, all category 3 and 4 pressure ulcers acquired in care are thoroughly investigated and The Trust has informed Bedfordshire CCG to further discuss reviewing commissioned levels of TVN service in the community. (AI summary)

View full response
Dear Mr Osborne am writing to set out the Trusts formal response to the Regulation 28: Report to Prevent Future Deaths, dated 15 December 2016. would like to begin by extending our condolences to the family of Mrs McHale_ hope this response provides them and you with assurance that the Trust are taking matter seriously and have an action plan to address the issues_ Although the Trust welcomes your remarks in court which indicate that you have no concerns about the care of Mrs McHale, we also acknowledge the concerns raised with regards to the number of Tissue Viability Nurses (TVN) available within our community health services_ In response to these, a service review has been undertaken. On reviewing the TVN service within the Trust, we can confirm that clear pathways are in place to ensure timely and effective referral to the service and we have increased provision of TVNs available over the past two years. Further to this, the community nurses although are not TVNs, do have ongoing training and monitoring to ensure are skilled in the prevention and early detection of pressure ulcers_ All category 3 and 4 pressure ulcers acquired in our care are thoroughly investigated through root cause analysis and 'Skin Matters panels to review care given and identify if any learning can be taken forward The Trust remains committed to continue to take action to reduce the number of pressure ulcers in the community and we have worked with the CCG, local authority and acute hospitals to support pathways, training and raising awareness CareQuallty Rona Commission "40e Ssttrall Good South Essex Partnership University NHS] NHS Foundatian Trust INVESTORS Gold IN PEOPLE Stonewall WWW SEPTnhs.uk FEB 2017 Sally the the they they bour Mive 1 015484t9

We have informed Bedfordshire CCG, who commissions our TVN service, of the outcome of the inquest: As a result, we are meeting with them shortly to further discuss reviewing the commissioned levels of TVN service in the community. Finally, would like to reiterate my condolences to Mrs McHale's family. hope that this response goes some way to providing assurance that the Trust regards their loss very seriously and has taken significant steps to review the TVN service and care and prevention of pressure ulcers in the community.

Report sections

Investigation and inquest
On 19 August 2016 commenced an Investigation into the death of Jean Marjorie McHALE aged 88 years The Investigation concluded at the end of the Inquest on 13 December 2016. The conclusion of the inquest was narrative that she had died from Sepsis from infected pressure ulcers_
Circumstances of the death
The deceased was admitted to Luton & Dunstable Hospital on 9 July 2016 Senior ( 'oroner The House: Woburn Street: AMPTHILL_ Bedfordshire: MKX 2HX Tel 0300-30u-6559 0300-300-8267 the Court Fat following confusion, fever and generally unwell. She had 2 large pressure sores (Grade
4) present on the sacral region. thorough discussion with microbiology she underwent multiple antibiotic therapy for 5 weeks; her condition unfortunately failed to improve_ Her Daughter stated that her mother was discharged from Hospital in April 2016 with Grade Pressure Sores and arranged for nurses to visit_ The deceased was seen by the Community Nurses and Carers on a daily basis_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you as Chief Executive have the power to take such action:
Copies sent to
6559 Fax 0300

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Report details

Reference
2016-0456
Date of report
15 December 2016
Coroner
Thomas Osborne
Coroner area
Bedfordshire and Luton

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Apr 2017 (estimated).

Sent to

Luton and Dunstable Hospital
South Essex Partnership NHS Trust

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