Susan Bracegirdle
2 Feb 2024 · Coroner Alison Mutch · Manchester South
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. pressure ulcer deterioration in care home setting
“because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers”
2. family unaware of patient condition
“family were unsighted on the condition of Mrs [name redacted] until shortly before her admission to hospital”
3. incomplete safeguarding review
“safeguarding review undertaken. However key people involved in her care had not provided input”
4. family excluded from internal review
“earlier internal review by the District Nursing team when Mrs [name redacted] pressure ulcer became a category 3 was not shared or discussed with the family and they were unsighted on the issue.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“The inquest heard evidence that because Mrs [name redacted] was in a care home setting the District Nurses were responsible for management of her pressure ulcers.”
Later report
“ii) There are concerns over the level of compliance of care plans.”
Responses
2024-0052-Response-from-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“We have reviewed all our records and cannot find that we received a statutory notification for serious injury to Mrs [name redacted] in relation to the grade 3 pressure injury identified at the point it was identified in October 2022.”
2024-0052-Response-from-Greater-Manchester-Integrated-Care.pdf ↗· Care Quality Commission
Stated action
“The care home was asked to ensure pressure relieving processes were followed. However, the District Nurses did not share care plans with the care team on the basis that they were digital documents and were care plans for the use of District Nurses. Consequently, the care home management were not fully sighted, and joint care was more difficult to deliver increasing the risk of the pressure ulcers deteriorating.”
Stated action
“Whenever a District Nurse attends a resident at Stable Steps any advice in relation to the management of pressure ulcers is shared with the team via a Communication Book.”