Doreen England
23 Jul 2015 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. pressure sores in elderly mental health patients
“Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared”
2. inadequate staff knowledge of pressure sore prevention
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk”
3. inadequate RMN training on pressure sore prevention
“Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge”
4. lack of clear leadership and medical cover on ward
“The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.”
Later report
“once Mr [name redacted] sacral sore had occurred, due to staff inexperience and lack of training, the equipment provided to reduce the further development of his sacral sore was either not utilised, or if utilised sometimes used incorrectly.”
Responses
2015-0291-Responses.pdf ↗· Department of Health and Social Care
Stated action · March 2016
“was to write to you again in March 2016 to confirm that all future actions have indeed been delivered.”