Eileen Cooke
25 Oct 2018 · Coroner Kevin McLoughlin · West Yorkshire (East)
The coroner's concerns
1. amputation of left leg at groin
“Consideration was given to an amputation of her left leg at her groin but it was recognised this would entail significant risks for a frail lady aged 80 with a range of co-morbidities”
2. discharge of patient with unresolved wound issues
“She was nevertheless deemed medically fit to be discharged from hospital on 7 November 2017 despite the progressive deterioration of the soft tissues around her left ankle fracture site and painful ulceration between her thighs”
3. lack of family involvement in discharge planning
“The family were not involved in her discharge from hospital at all. It was arranged in haste. Inadequate Preparatory work had been done to establish how her wound dressing could be carried out and the pain control needed whilst this was done”
4. inadequate discharge planning leading to unresolved problem transfer
“Evidence taken from healthcare professionals at the Inquest indicated thatthe | 7.11.17 discharge was an error of judgement. it effectively passed an unresolved problem to a nursing home”
5. absence of multidisciplinary best interests meeting
“A''best interests' meeting was required to assess her needs and formulate a management plan. This should have involved the orthopaedic surgeon, the vascular surgeon, nurses, a physio-therapist, a care of the elderly physician, a Palliative care specialist, the general practitioner and the family”
6. precipitous discharges endangering other patients
“Having heard the evidence relating to the treatment received by this vulnerable elderly lady, | am concerned that the safety of others may be put at risk by precipitously arranged discharges”