Karen Day

“During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same”

“During the inquest I received evidence that the practice had not carried out any internal investigation in relation to this death and the practice accepted it should have done. I am concerned that the practice does not have adequate systems in place to ensure that patient safety incidents are reviewed in a timely way to allow lessons to be drawn from the findings.”