Arthur Cook
27 Jul 2015 · Coroner Sarah-Jane Richards · Powys, Bridgend and Glamorgan
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. low staffing of Tissue Viability Nurses
“Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need”
2. inadequate pressure ulcer documentation and repositioning charts
“The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal”
3. lack of integrated skin care
“An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region.”
This report
“Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need”
Closely relatedConfidence 0.80 · moderate
This report
“Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need;”
Later report
“Mrs [name redacted] confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.”
Responses
No published response was found on judiciary.uk.