Barbara Cooke
12 Sept 2014 · Coroner Caroline Sumeray · Isle of Wight
The coroner's concerns
1. insufficient staffing leading to neglect of basic care
“During the course of the evidence, it became clear that the resident to staff ratio of 20:2 during between 2 p.m. and 9 p.m. was inadequate to deal with all the residents' needs at Waxham House”
2. infection risk from prolonged exposure to waste
“I am concerned that the Waxham House Residential Care Home didn't recognise the obvious risks of infection of leaving an incontinent lady sitting in her own waste when she was prone to sacral sores”
3. lack of escalation protocol for delayed nursing response
“I am concerned that there appears to be no protocol at Waxham House to chase up the District Nurse Service if they haven't responded to a message within 24”
4. missing safeguarding documentation on hospital admission
“I am concerned that there does not appear to be a system in place at St Mary's Hospital to record on admission that a patient is the subject of an open Safeguarding concern”
5. failure to automatically refer safeguarding-related deaths to coroner
“I am further concerned that there is currently no system in place at St Mary's Hospital to automatically contact the Coroner to refer the matter for investigation when a person who is the subject of a Safeguarding alert dies whilst an inpatient in the Hospital”
6. failure to automatically notify safeguarding team of alert-related deaths
“I am concerned that there is currently no system in place at St Mary's Hospital to automatically notify the IOW Safeguarding Team if someone who is the subject of an open safeguarding alert dies whilst an inpatient in the Hospital”
Responses
No published response was found on judiciary.uk.