Alan Nippard
24 Jul 2023 · Coroner Maria Voisin · Avon
The coroner's concerns
1. hospital acquired pressure sore
“the pressure sore was preventable, that it's basic nursing care and this wasn't achieved. That once it had developed, if he'd had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was”
2. inadequate risk assessment and prevention of pressure sore
“screening tool completed on 31st May scored Mr [name redacted] as, not at risk of a pressure sore - this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr [name redacted] should have been on an air mattress and he should have been re-positioned regularly”
3. unmanaged heel pressure injury
“On 11th June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report - this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all”
4. lack of weight monitoring
“He wasn't weighed which would have assisted with managing his oedema”
5. inadequate fluid balance monitoring
“Fluid balance charts were poorly completed”
6. inadequate pressure care
“Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care”