Source · Prevention of Future Deaths
Mohammed Chaudhury
Ref: 2013-0193
Date: 20 Aug 2013
Coroner: Andrew Harris
Area: London (Inner South)
Responses identified: 0 / 2
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The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Date
20 Aug 2013
56-day deadline
15 Oct 2013 est.
Responses identified
0 of 2
Coroner's concerns
The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
View full coroner's concerns
(1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care_on Murray Falconer ward in KCH
Report sections
Investigation and inquest
On 1th July 2010 opened an inquest into the death of Mohammed Mozammel Chaudhury: The investigation concluded at the end of the inquest on 2" August 2013. The medical cause of death was 1a Overwhelming sepsis 1b Chest and other infection Ic Traumatic brain injury: The conclusion of {he inquest was a narrative determination:
Circumstances of the death
Mohammed Chaudhury suffered multiple injuries from a traffic collision on 7lh September 2009. He was cared for in Kings College Hospital initially in ITU when he was immobile due to fractured pelvis and was at high risk of bed sores due to minimal consciousness, peripheral vascular disease, diabetes and PEG feeding: He was transferred to a step down ward without pressure sores on 27/h September. There he developed a number of infected pressure sores, which were due to not being nursed on an air mattress for three weeks and insufficient turning due to shortage of nursing staff. He was transferred to a nursing home with five pressure sores between grades 2 and 4, which were septic.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:
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Report details
- Reference
- 2013-0193
- Date of report
- 20 August 2013
- Coroner
- Andrew Harris
- Coroner area
- London (Inner South)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Oct 2013 (estimated).
Sent to
- Care Quality Commission
- King’s College Hospitals NHS Foundation Trust