Arthur Cook

On the 21st April, 2015 I commenced an investigation into the death of Mr. Arthur Cook, 78 years old. The investigation concluded at the end of the inquest on the 3rd

July, 2015. The conclusion of the inquest was ‘Death from a poorly managed MRSA infected wound’.

Mr. Arthur Cook suffered from poor circulation and was being treated by vascular surgeons for gout and necrosis of his toes leading to toe amputation. Since March 2014, he had been a patient under the care of both the Aneurin Bevin Hospital Board (ABHB) and the Cwm Taff University Health Board (CTUHB). During this period he had been admitted to the Royal Glamorgan Hospital; the Ysbyty Ystrad Fawr; and the Four Seasons Healthcare Residential Home where he was under the medical supervision of the Bryntirion Surgery, Bargoed, all of which are under the ABHB.

Mr. Cook had further periods of hospitalisation in Prince Charles Hospital which is administered by CTUHB. He was discharged from Ward 31, Ysbyty Ystrad Fawr to the Four Seasons Healthcare Residential Home on 14th

January, 2015 with a chronic open wound to his right knee - an injury sustained when a patient in the Royal Glamorgan Hosptial. Whilst a resident at the Four Seasons Healthcare Residential Home, Mr. Cook developed a wound (possibly pressure ulcer) to the back of the right knee. On the 25th

January 2015 the wound exudate was assessed as ++. At this time tissue viability care was sought from the ABHB and again in February 2015 but the residential home Manager was advised of the lack of availability of specialist nursing advice at that time. TVN advice was not provided until April 2015. At this time Mr. Cook was admitted to Prince Charles Hospital with an MRSA infected category 4 pressure ulcer. He failed to respond to treatment and subsequently passed away.

in the area of prevention, diagnosis and treatment of escalating pressure ulcers by:

 Ensuring microbiology results which confirm MRSA infectivity are notified to the GP and Community nurses and Residential home staff involved in the treatment of a residential home patient even when results pertain to a patient in a different Health Board’s area;

 For the ABHB to ensure staffing levels of tissue viability nurses are such that vulnerable patients (including the elderly who have limited mobility) have access to specialist services to inhibit the escalation of pressure ulcers to the point they are causative of death through infection; and

 GPs to be proactive in checking their elderly residential patients are receiving expert nursing input when required.