Joan Richardson
1 Jul 2022 · Coroner Julie Goulding · Sefton St Helens & Knowsley
The coroner's concerns
1. general deterioration not escalated
“The matter of [the deceased]'s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc”
2. pain complaints not escalated
“When [the deceased] complained of pain -the matter was not escalated as it should have been”
3. absence of comprehensive care plan risk assessment pressure area care
“There was no comprehensive plan of care, risk assessment, pressure area care Regulation 28 - After Inquest Document Template Updated 30/07/2021 plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services”
4. pressure ulcers not documented managed
“[the deceased] was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because [the deceased] had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, [name redacted] nurse or social care team informed to enable them to commence/prescribe appropriate treatment”
5. lack of skin integrity monitoring
“There were no records/daily log making any mention of skin integrity/breakdown even though [the deceased] was in bed, frail, immobile and incontinent in addition to which because [the deceased] was refusing care her incontinence pads were not being changed regularly”
6. inadequate staff training escalation procedures
“Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate”