Thomas Jenkins
19 Dec 2014 · Coroner Sarah-Jane Richards · Powys, Bridgend & Glamorgan Valleys
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed tissue viability nursing assessment leading to ulcer deterioration and new ulcer formation
“Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. [name redacted] was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as 'very offensive'. A bandage used was reported as the likely cause of a new ulcer forming - Datix incident report 14.07.14”
2. insufficient tissue viability nursing staff and lack of onsite specialist nurses
“inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region.”
Later report
“Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need”
Responses
No published response was found on judiciary.uk.