Leonard Hudson
24 Sept 2014 · Coroner not stated · Sunderland
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. pressure ulcer development
“During the course of Mr [name redacted] in-patient admission from the 13" of May 2013 to the 13" of August 2013, staff did not follow the requirements of the Trust' Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.”
2. risk factor identification
“Due to the co-morbidities of Mr [name redacted], he ought to have been identified as having a higher risk factor.”
3. delayed foot protection referral
“Mr [name redacted] ought to have been referred to the foot protection team in a more timely manner.”
4. incomplete nursing documentation
“The nursing documentation was not as comprehensive as it ought to have been.”
5. inconsistent injury classification
“The classification of Mr [name redacted] heel injuries was”
6. inadequate record keeping
“there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr [name redacted] was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
This report
“The nursing documentation was not as comprehensive as it ought to have been.”
Responses
No published response was found on judiciary.uk.