Ronald Farrington
22 Dec 2017 · Coroner Caroline Topping · Surrey
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. incorporation of tissue viability advice
“Failed to incorporate all the advice given by the tissue viability nurses in Mr [name redacted] care plans”
2. inaccurate record keeping
“Failed to keep accurate records”
3. misrepresentation of nurse involvement
“Informed the CQC that the tissue viability nurses were still involved with Mr [name redacted] when they weren't”
4. non-compliance with turning advice
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
5. failure to refer for infection
“Failed to refer Mr [name redacted] to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016”
6. inadequate nurse staffing
“Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th 2 March and the 15th June 2016. This was not an adequate level service”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Failed to keep accurate records.”
Later report
“Furthermore, the general quality of record keeping was poor.”
Closely relatedConfidence 0.90 · high
This report
“Failed to keep accurate records.”
Later report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Closely relatedConfidence 0.85 · high
This report
“Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr [name redacted] sores”
Later report
“There are concerns over the level of compliance of care plans.”
Responses
2017-0494-Response.pdf ↗· Care Quality Commission
Stated action · December 2017
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Ronald-Farrington-Response.pdf ↗· Care Quality Commission
Stated action
“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”