Source · Prevention of Future Deaths
Dorothy Imisson
Ref: 2016-0496
Date: 5 Apr 2016
Coroner: James Adeley
Area: Preston and West Lancashire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
Date
5 Apr 2016
56-day deadline
7 Jun 2016
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
View full coroner's concerns
_ (1) No appropriate care plan was developed by the District Nursing Service.
2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping (3) The District Nursing Services are compromising patient care by not following NICE guidelines.
2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping (3) The District Nursing Services are compromising patient care by not following NICE guidelines.
Report sections
Investigation and inquest
On 29/09/2014 commenced an investigation into the death of Dorothy Imisson, aged The investigation concluded at the end of the inquest on 05/04/2016_ The conclusion of the inquest was: Dorothy Imisson died on 9 August 2014 at Cleveleys Nursing Home from naturally occurring stroke caused by atrial fibrillation: Dorothy Imisson's death was contributed to by an absence of pressure care planning by qualified staff resulting in a premature development of severe skin ulceration, shortening of life and increased pain and suffering:
Circumstances of the death
The circumstances of the death are set out in the attached Summing Up and Conclusion.
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
- 2016-0496
- Date of report
- 5 April 2016
- Coroner
- James Adeley
- Coroner area
- Preston and West Lancashire
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: 7 Jun 2016 (stated in the report).
Sent to
- Blackpool Teaching Hospitals NHS Trust
- Care Quality Commission