Norman Beard

1. 1. poor management and absences of management staff

   “Poor management and absences of management staff was evident during the inquest”

2. 2. shortage of staff, food and other equipment

   “Financial difficulties led to shortage of staff, food and other equipment”

3. 3. lack of clear policies and procedures

   “There were no clear policies and procedures in place”

4. 4. delayed referral of pressure ulcers to tissue viability nurses and unheeded advice

   “Mr [name redacted] deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed”

5. 5. lack of referral for weight loss to dietitian physiotherapist mental health services and district nursing

   “Mr [name redacted] lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams”

6. 6. minimal GP involvement and no follow up on abnormal blood tests

   “The involvement of the GP was minimal and there was no follow up when blood tests tevealed an abnormality”

No published response was found on judiciary.uk.