Raymond Reid
28 Nov 2024 · Coroner Philip Spinney · Devon, Plymouth and Torbay
The coroner's concerns
1. sepsis from combined UTI pressure sores and pneumonia
“Mr [name redacted] died as a consequence of sepsis caused by a combination of a urinary tract infection (UTI), pressure sores and pneumonia; it was established during the evidence that it would not be possible to determine to what extent the infection resulting from the UTI, the pressure sores and the pneumonia individually contributed to the cause of death.”
2. pressure sore deterioration due to care gaps
“The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that: a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy. b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy. c.”
3. incomplete skin check documentation
“Skin checks were not routinely documented - there were 21 intermittent days when a skin check was not recorded.”
4. missing malnutrition screening
“A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.”
5. prolonged immobility leading to pressure sore progression
“There were long periods when Mr [name redacted] was not moved - there were episodes during 15/2/23 to 21/2/23 when Mr [name redacted] was not documented to have moved for 5-10 hours. This is not best practice.”
6. lack of wound follow up after tissue viability assessment
“Following a Tissue Viability Team assessment there was no follow up planned - this should have been planned to monitor wound progression.”