Dorothy Townley

28 Aug 2013 · Coroner Joanne Kearsley · Manchester (South)

The coroner's concerns

1. lack of direct communication between District Nurses and GP regarding condition and required visits
“There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased's condition was and what was required on visits. There was no consideration given to carrying out joint visits, no communication as to how Mrs [name redacted] wound could be examined if there were no dressings available.”
2. lack of knowledge within District Nursing Team about treatment of burns
“There was a lack of knowledge within the District Nursing Team around the treatment of burns.”
3. inadequate wound assessment chart for burns
“The wound assessment chart did not assist as it was not as detailed as it should be for burns in order to help chart their progress or deterioration.”
4. lack of training for District Nurses on burn treatment
“There was a lack of training for District Nurses on the treatment of burns.”
5. lack of understanding between GP and District Nurses about urgent blood test requests
“There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests. It was assumed by the GP that his request for a blood test would be treated as urgent and done that day (on 10"): the District Nurses indicated it would only be carried out as 'urgent' if requested.”