Dorothy Macey
13 Nov 2019 · Coroner Sonia Hayes · Mid Kent and Medway
The coroner's concerns
1. failure to photograph leg wounds
“Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits”
2. lack of information sharing with GP
“District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime”
3. incomplete electronic care records
“The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition”
4. missed sepsis pathway check
“A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September”
5. unauthorised dressing change
“District nurse support staff changed the type of leg dressings without approval of the qualified nurses”
6. incomplete medication charts
“Medication administration charts completed by carers were incomplete”
Responses
No published response was found on judiciary.uk.