June Evans
19 Oct 2017 · Coroner Caroline Topping · Surrey
The coroner's concerns
1. delayed referral of grade 3 pressure sore
“failure to refer the hospital acquired grade 3 pressure sore to the tissue viability nurse on the 8th [the deceased] 2016 was as a result of the employment of an agency nurse who was unfamiliar with the Trust's Policy on the Prevention of Pressure Sores”
2. clinicians unaware of pressure sore
“The treating clinicians were unaware that Mrs [name redacted] had developed a grade 3 hospital acquired pressure sore, noted on the 8th [the deceased] 2016, until the 15th [the deceased] 2016”
3. nutrition advice not implemented
“Dietician's advice in respect of the quantity of nutrition required by Mrs [name redacted] was not implemented by the nursing staff”
4. inadequate staffing across multiple wards
“Mrs [name redacted] was nursed on 3 wards from the 4th to the 30th [the deceased]”
Responses
No published response was found on judiciary.uk.