Ronald Ashdown
18 Jul 2023 · Coroner Sean Horstead · Essex
The coroner's concerns
1. genital hygiene neglect
“Upon [the deceased]'s arrival back at the Nursing Home on 2nd August, staff immediately raised a Safeguarding concern in respect of, inter alia, his genitals being covered in a white”
2. failure to share critical evidence
“The Trust's responsible Adult Safeguarding Lead provided a statement in which [REDACTED] confirmed that, notwithstanding the photos having been expressly noted in the original Safeguarding referral and raised in subsequent correspondence and meetings with the Thurrock Local Authority Safeguarding Team, [REDACTED] had not made the photos available for the purposes of the RCA”
3. misrepresentation of care documentation
“The evidence heard at the inquest undermined the following erroneous findings of the RCA: · In response to the concern that [the deceased] had extensive flakes of fungal growth behind his ears the RCA concluded that”
Responses
2023-0249-Response-from-Mid-and-South-Essex-NHS-Foundation-Trust-1-1.pdf ↗· Mid and South Essex NHS Foundation Trust
Stated action · later this month
“We are planning to launch a ward manager supervisory role with linked key performance indicators later this month which will allow closer supervision and audit of the nursing care provided This will include monitoring the quality of the nursing care we provide”