Maureen Powell
11 Jun 2025 · Coroner Gordon Clow · Nottingham City and Nottinghamshire
The coroner's concerns
1. lack of daily skin inspections
“widespread non-compliance with the regime of daily skin inspections in the period of time that [the deceased] was a resident at the Nursing Home. Not one skin inspection was recorded during [the deceased]'s stay”
2. delay in appropriate bed surface
“There was a delay in putting an appropriate bed surface in place”
3. incorrect airflow mattress adjustment
“On at least one occasion the airflow mattress was incorrectly adjusted, reducing its efficacy”
4. late tissue viability referral
“The referral to tissue viability was made too late as it occurred after the wound had got beyond the ability of the in-house nursing staff to manage and treat the wound”
5. lack of internal investigation
“No internal investigation was undertaken”
6. key records not kept
“Key records were not kept or were lost or destroyed”