John Pearce
25 Feb 2019 · Coroner Edwin Buckett · London Inner (North)
The coroner's concerns
1. delayed emergency response to deteriorating wound
“There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted”
2. insufficient nursing visits
“There were insufficient attendances on Mr [name redacted] by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals”
3. overreliance on patient preference
“Too much emphasis was placed on Mr [name redacted] own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself”
4. lack of wound image sharing
“There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased's GP”