Carol Divall
14 May 2024 · Coroner Rachel Redman · East Sussex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. oral thrush causing dysphagia and medication non‑adherence
“Mrs [name redacted] developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication”
2. grade 4 sacral pressure sore
“Mrs [name redacted] developed a grade 4 sacral pressure sore”
3. inadequate root cause analysis
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
Later report
“Poor management of [the deceased]'s pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol.”
Responses
2024-0263-Response-from-East-Sussex-Healthcare-.pdf ↗· East Sussex Healthcare NHS Trust
Stated action · 2022
“case. We recognise that the mouthcare received by Mrs [name redacted] was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording. High risk patients now receive daily mouthcare reviews, medium risk patients”
Stated action · mid-May
“We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur. We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.”
Stated action · 20 September 2022
“We acknowledge the unacceptable delay in dealing with the pressure sore. We note that category 2 pressure damage was first documented in Mrs [name redacted] health records on 20 September 2022, ten days before the referral to the TVN. In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential”