Source · Prevention of Future Deaths
Iris Grimwood
Ref: 2014-0384
Date: 26 Aug 2014
Coroner: ARW Forrest
Area: South Lincolnshire
Responses identified: 0 / 1
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Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Date
26 Aug 2014
56-day deadline
2 Oct 2014
Responses identified
0 of 1
Coroner's concerns
Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
View full coroner's concerns
The MATTERS OF CONCERN as follows Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush; before being stopped by a family member_ The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training_
Report sections
Investigation and inquest
On 16th October 2013 commenced an investigation into the death of Iris GRIMWOOD, age 80. The investigation concluded at the end of the inquest on 22nd August 2014_ The conclusion of the inquest was NATURAL CAUSES_
Circumstances of the death
Iris was well for her age, apart from dizziness for some 14 years which had been treated with prochlorperazine_ When this drug was stopped her condition deteriorated. She developed a tremor which became more prominent after July 2013. From then on her condition deteriorated and she went down hill. Drug induced Parkinsonism contributed to her symptoms in the early stages of her illness. Lewy body dementia was thought to be a cause when she developed visual hallucinations_ Concerns were expressed about the quality of nursing care during her decline, but no evidence presented suggested that this contributed to her death. She died in Pilgrim Hospital on 8th October 2013 as a result of her progressive neurological disease Unit 1,_ Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk May
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire_
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
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Report details
- Reference
- 2014-0384
- Date of report
- 26 August 2014
- Coroner
- ARW Forrest
- Coroner area
- South Lincolnshire
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: 2 Oct 2014.
Sent to
- United Lincolnshire Hospitals NHS Trust