Cynthia Gilbert

“Mrs [name redacted] was noted to have grade 2 tissue damage on admission to hospital. She was assessed as being at very high risk of pressure ulcer development. Her care plan included repositioning every 1 to 2 hours. The Intentional Rounding documents show that, during her time spent on the Old Acute Medical Unit and Coleridge Respiratory Unit (1/9/23 to 20/12/23), Mrs [name redacted] remained in the same position in bed for periods of many hours on multiple days.”

“The lack of adherence to the repositioning care plan for a patient at very high risk of developing pressure ulcers raises a concern for future deaths.”

“The evidence given by the Trust at the inquest did not provide a satisfactory explanation as to why the repositioning care plan was not adhered to. This raises a concern about the quality and efficacy of the Trusts' post-death investigation which in turn raises a concern for future deaths.”