Jane Bruce

1. 1. inconsistent wound monitoring by multiple district nurses

   “Ms [name redacted] was care for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for continuity / reference to and the electronic records could not be accessed by the District Nurses while they were in Ms [name redacted] home. This meant that all information that could have been available was not. This meant that Ms [name redacted] change in condition was not fully appreciated.”

2. 2. delayed wound assessment and lack of real‑time data

   “Leicestershire Partnership Trust have learned from this and District Nurse now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a 'sepsis' bag containing equipment to record the blood pressure, oxygen saturation levels and temperature.”

3. 3. potential replication of inadequate wound monitoring practices

   “the practice that was in place at the time of Ms [name redacted] death may be practice elsewhere”

No published response was found on judiciary.uk.