Isabella McCreadie
3 Jun 2024 · Coroner Krestina Hayes · Surrey
The coroner's concerns
1. insufficient dietician staffing
“In evidence I was advised during Mrs [name redacted]'s stay in hospital her dietetic needs were not addressed as there was insufficient staffing in the dietician department. I asked the hospital when giving evidence if these issues had been addressed and was advised that there were still ongoing. I am concerned that if appropriate staffing levels are not put in place, patient's needs will not be met.”
2. inadequate pressure sore training
“During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs [name redacted]. I have been advised in submissions by the hospital that they intend to address this training need by identifying e- learning staff can complete. Given in evidence it was identified that a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned; and b) the staff are unaware of the techniques needed to”
3. unprocessed dietary supplement order
“During the doctor's evidence, at inquest, an issue was highlighted regarding ordering of fortsips on the hospital computer system, a dietary supplement. An order had been made to be started on 10th May to 3rd June twice daily. This was not processed. I was advised in evidence by the hospital that the doctor could be shown how to release it. However, there is no evidence as to how this error could be identified if it should reoccur and a clinician was not aware that the order for fortsips was not”
4. insufficient agency staff training
“At the time of the inquest, I was informed during Mrs [name redacted]'s stay a number of staff were agency staff. I note that the hospital now have more permanent staff in place on the ward than when Mrs [name redacted] was on the ward. I remain concerned that agency staff who may still need to be called to assist on the ward may not have sufficient training on the computer system used for recording medical care provided before they are required to do so whilst working on the ward. At the inquest there was”
Responses
2024-0300-Response-from-Frimley-NHS.pdf ↗· Frimley Health NHS Foundation Trust
Stated action
“The Trust seeks to reassure you that resources in the dietetics team are being used as effectively as possible to ensure patient's needs are appropriately met and bank work is being offered where appropriate.”
Stated action
“the Trust will be introducing a new skin assessment tool (PurposeT). This tool is prescriptive with regards to actions that should be taken once a patient's pressure areas have been assessed. This is as a result of a new National Wound Care Strategy initiative. There will be training to all nursing staff on how to use this skin assessment tool.”
Stated action
“the Trust will be introducing a new skin assessment tool (PurposeT). This tool is prescriptive with regards to actions that should be taken once a patient's pressure areas have been assessed. This is as a result of a new National Wound Care Strategy initiative. There will be training to all nursing staff on how to use this skin assessment tool.”