Jean Miller

a swab being taken on 18th December 2012. 8, During their care of Mrs Miller the district nursing team carried out a number of checks on Mrs Miller to try to identify if her condition was deteriorating: However I was told that did not take her temperature whilst caring for her: The inquest was told that district nurses within the trust did not take temperatures as part of their routine care and were not expected to.The inquest was further told that the district nurses were not issued with thermometers as part of their medical kit when caring for patients.
10.One of the district nurses indicated that if she was worried a patient had temperature then she would check their forehead to see if they felt hot;
11.Mrs Miller was readmitted to the Royal Bolton Hospital on December 2012 with what was described as purulent discharge from the wound site: She received treatment at the Royal Bolton Hospital following her admission including further surgical intervention and was on the intensive care ward: She died on 24th January 2013 at the Royal Bolton Hospital: The evidence I heard at the Inquest established that:
1. The wound was not of concern at the time of discharge from the Royal Bolton Hospital and had there been concerns Mrs Miller would not have been discharged,
2. The district nursing team were not able to fully monitor any possible deterioration of the wound in the absence of a baseline assessment
3. The specialist services of the Tissue Viability team were not accessed by the District Nursing Team
4. The basic nursing check of temperature taking using a thermometer was not carried out by the district nursing team and there was no expectation of such an action being carried out by their management team
5. District Nurses with the Pennine Trust are not issued with thermometers to assist them in the care of patients
6. The quality of the notes kept by the District Nursing Team was poor
7. There was limited communication with the GP notwithstanding the proximity of the District Nurses to the GP Miller's wound had significantly deteriorated by the time the District Nursing Team identified she could no longer be cared for at home and required readmission to hospital My main concerns arising from the Inquest are: -
1. The quality of care offered by the district nursing team arising from poor they they 24th Mrs practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller's 2, The lack of basic equipment issued to the District Nursing Team in particular thermometers
3. Poor record keeping by the District Nursing Team
4. Poor communication by the District Nursing Team with the GP Accordingly, I request the Trust to carry out a review of:
1. How the quality of patient notes are assessed and procedures to ensure that there is substantial improvement in the quality of record keeping:
2. The equipment issued to the District Nursing Teams to ensure that all District Nurses are in a position to carry out basic nursing checks such as temperature checks The systems in place for carrying out baseline assessments of patients under the care of the District Nursing Team The understanding of the District Nursing Team of the role of the Tissue Viability Team and when their expertise should be utilised
5. Methods of and recording of communication with GPs By virtue of Rule 43A() as a recipient of this report you must provide me with written response to it containing details of any action taken or which it is proposed be taken: This must be provided within fifty six days beginning with the day upon which this report is sent: If you wish to request longer than this period to respond you should write to me requesting an extension of time and giving reasons. In accordance with Rule 43 a copy of this report is being sent to the Secretary of State for Health and all other properly interested persons identified at the Inquest: A list of recipients can be found at the end of this letter. Your response will be shared with those listed. I look forward to hearing you: Yours sincerely Akog Alison P Mutch H M Assistant Deputy Coroner Greater Manchester County (West) Copies to Secretary of State for Health from