Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate staff knowledge of pressure sore prevention and equipment use
The earlier warning
Doreen England · 23 Jul 2015 · Louise Hunt, Birmingham and Solihull
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
judiciary.uk/prevention-of-future-death-reports/doreen-england
What was promised
Stated action 1 · response to Doreen England (23 Jul 2015) · stated timescale: March 2016
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”
judiciary.uk/wp-content/uploads/2015/07/2015-0291-Responses.pdf
What recurred
- 17 Aug 2021 · Roland Stannard · Nigel Parsley · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Doreen England · 23 Jul 2015
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
Later · Roland Stannard · 17 Aug 2021
“once Mr [name redacted] sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly.”
What happened next
No web check of the stated actions has been published for this chain.