Mavis Lawrence
30 Sept 2020 · Coroner Margaret Jones · Stoke-on-Trent & North Staffordshire Coroner's Court
The coroner's concerns
1. pressure area not checked
“Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes.”
2. lack of wound treatment assessment charts
“No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas.”
3. unclear documentation of positioning
“Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers.”
4. pressure mattress turned off
“The pressure mattress had been turned off on the 22.1.19”
5. no record of district nurse visit
“No record of last visit by district nurses on the 27.1.19”
6. band 4 nurse did not escalate
“There was no evidence that band 4 nurse escalated the seriousness of the situation.”
Responses
2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf ↗· Midlands Partnership NHS Foundation Trust
Stated action · 31.01.2021
“We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).”