Source · Prevention of Future Deaths

James Bateley

Ref: 2015-0115 Date: 23 Mar 2015 Coroner: Penelope Schofield Area: West Sussex Responses identified: 2 / 2 View PDF

Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

Date 23 Mar 2015

56-day deadline 18 May 2015 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

View full coroner's concerns

In the circumstances it is my statutory duty to make this report to you. During the evidence it became apparent that neither the nursing home, where Mr Bateley was living, nor the Community Nurses_ who had been called in to assist in treating Mr Bateley's pressure sores had ready access to the necessary dressings There was evidence given that these dressings are not readily available to nursing homes or the Community Nurses who regularly have to treat this type of ailment The dressings have to be ordered through the GP and we were told that it could take up to 14 for them to arrive In Mr Bateley's case staff had to borrow and make use other residents dressings Mr Bateley was taken into_hospital before_his dressings arrived,Whilst the absence of these dressing _was_ 5981872.1 24th being due days Sadly unlikely to have contributed directly to Mr Bateleys death there is concern for others in the future who cannot rely on others to borrow dressing from.

Responses

2 respondents

Coastal West Sussex Clinical Commissioning Group NHS / Health Body

5 May 2015 PDF

Action Taken

The CCG contacted the Deputy Chief Nurse, Sussex Community NHS Trust to investigate the delay in ordering dressings, and assurance was obtained from the Pharmacy that there was no delay in processing the order. The Residential Care Home has completed a review of their Management of Prescriptions policy. (AI summary)

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Dear Ms Schofield Re: Inquest into the death of James BATELEY 10 March 2015 Further to your letter dated 24 March 2015 highlighting matters of concern and the need to investigate the issues raised, we confirm the following: The matter was referred to our Quality Assurance team whereby a representative met with the Head of Medicines Management CWS CCG, Deputy Designated Nurse: Safeguarding Adults, CWS CCG, the Residential Care Home concerned and representative of the GP Surgery to investigate dressings not being available and the process undertaken by the Community Nurses who regularly to treat this type of ailment and the delay in the order of such dressings: The timeline of events was as follows: Need for dressings raised 13 2014 First order request submitted 28 May 2014* Further request submitted 2 June 2014 First order received 31 May 2015 Second order received 5 June 2015
*This resulted in a 15 day delay in ordering: The action to be taken will be to contact the Deputy Chief Nurse, Sussex Community NHS Trust to investigate fully the reason for delay in ordering; together with application and use of non-prescribed dressings. This action was completed by Friday 1 May 2015. Goring have May

Assurance has been obtained from the Pharmacy used by the Residential Care Home and we are satisfied there was no delay in processing the dressings order. The Residential Care Home have completed review of their Management of Prescriptions policy to monitor and ensure there will be no further delays for their residents in relation to prescribed dressings We would like to reaffirm the patient did receive appropriate treatment by the Community Nurses and the delay in the prescription request was not detrimental to the patient's physical health, as the appropriate dressings were used from within the Residential Home's stock.

Sussex Community NHS Trust NHS / Health Body

19 May 2015 PDF

Action Taken

Immediate actions taken include meeting with the CCG, implementing a 'Stock box/First Dressing' system, and implementing an escalation process for delays in dressings supply. Longer-term actions are being discussed with the CCG to implement an ONPOS (On-line Non Prescription Ordering Service) in shadow from July, with full rollout planned from January 2016. (AI summary)

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Dear Ms Schofield Re: Inquest touching the death of James Bately 10th March
2015. Regulation 28 Report to Prevent Future Deaths Further to you Regulation 28 in conjunction with the above inquest am pleased to provide you with copy of our action plan designed to improve the provision of dressings for our patients _ number of immediate actions have already been taken, namely: Meeting with the Clinical Commissioning Group to discuss the concerns (CCG) Implementation of a 'Stock boxlFirst Dressing' system Implementation of an escalation process for delay in response for dressings supply Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS, (On-line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016 The immediate actions taken already ensure that patients receive appropriate dressings at the start of their care, with the longer term issues providing a more 'seamless service for our patients Ifyou would find it_helpful to_have more information on these actions, please do not hesitate to contact on the number above who will arrange for someone to provide this Page of 2 issuing will

Report sections

Investigation and inquest

On 13th June 2014 commenced an investigation into the death of James Bateley, born on November 2014, 88 years of age. An Inquest was opened on 13th June 2014 and was concluded on 10th March 2014

Circumstances of the death

Mr Bateley was admitted to Worthing Hospital on 30" May 2014 as he was medically unwell. Severe pressure sores with necrosis of tissue on buttocks and scrotal area were documented, safeguarding alert was rajsed to the severity of these pressure sores Mr Bateley died on 6th June 2014. A post mortem examination was carried out and the pathologist gave as the course of death Ia. Bronchopneumonia & Sepsis 1b. Necrotising Fasciitis Ic. Pressure Wound Ischaemic Heart disease

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation, can take such action

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0115
Date of report: 23 March 2015
Coroner: Penelope Schofield
Coroner area: West Sussex

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 May 2015 (estimated).

Sent to

NHS Coastal West Sussex Clinical Commissioning Group

Sussex Community NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.