Christopher Byron

1. 1. lack of documented referral policy for District Nurses to TVNs

   “the death of Mr [name redacted] the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs. "Unofficial" referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes. The Court heard evidence that such a referral was thought to have”

2. 2. unclear 30 minute observation requirement

   “In the most recent guidance from the Royal College of Nursing dated May 2019, "Iron Deficiency and Anaemia in Adults" the instruction to nurses is for them to "observe the patient for 30 minutes”

3. 3. inaccurate post mortem report

   “quality of the post mortem examination report produced i was wholly unsatisfactory and proven inaccurate. This meant both the bereaved family and the Trust were initially provided with an inaccurate medical cause of death. As a direct consequence the ability to learn lessons in order to prevent future deaths was not captured in a timely manner. It was not until the Coroner obtained a report fro in 2018 that anaphylaxis was offered as a potential cause of death”

4. 4. insufficient dressing supply for pressure sores

   “The Court heard evidence that at times there was a lack of appropriate dressings in order to treat Mr [name redacted] infected pressure sores. The Court heard evidence the District Nurses cannot order more than two weeks worth of dressings for any individual patient and cannot hold extra stock”

5. 5. lack of observation recording during iron infusion

   “The Court heard the Trust Guideline 'Patient Blood Management of Medical Patients' indicated the patient was to be observed for 30 minutes during the administration of the iron infusion. Due to a lack of recording the nurse who administered the iron infusion on the 30" December 2017 could not be identified”

Linked reports

No published response was found on judiciary.uk.