5 Nov 2019 Christopher Byron · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Insufficient access to appropriate dressings for severe pressure sores View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Christopher Byron · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient access to appropriate dressings for severe pressure sores
Wider context from the report “1. The Court heard evidence that at times there was a lack of appropriate dressings in order to treat Mr Byrons infected pressure sores. The Court heard evidence the District Nurses cannot order more than two weeks worth of dressings for any individual patient and cannot hold extra stock . In Mr Byrons case due to the severity and location of the pressure sores there were times when he used more dressings, especially if they came away from the wounds. This could lead to a shortage and meant him having to wait for dressings . In someone with severe pressures sores the requirement to have access to the appropriate dressings is important. The Court heard this instruction regarding the ordering of dressings is governed by the Clinical Commissioning Group.
” Source location Christopher Byron · Prevention of Future Deaths report
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25 Feb 2019 John William Pearce · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Insufficient district nursing attendances after increased visit frequency was identified as necessary View source Failure to share wound photographs for timely escalation decisions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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John William Pearce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Pearce was a frail 90-year-old man who developed a worsening left knee wound after an injury in April 2018 and died in hospital on 21 September 2018. The report identified concerns about delayed hospital referral, insufficient district nursing attendances, reliance on his reluctance to attend hospital, and inadequate systems for recognising and sharing information about worsening wounds.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient district nursing attendances after increased visit frequency was identified as necessary
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals ;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.
” Source location John William Pearce · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to share wound photographs for timely escalation decisions
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP , such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency .
” Source location John William Pearce · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Verbatim wording from the response “It is completely unacceptable that this policy was not consistently adhered to by the staff involved in Mr Pearce’s care. In response to this, the Divisional Director of Nursing and the Inner London Lead Nurse met with the team involved in this gentleman’s care on 19 March 2019 to discuss the findings of the PFD, reiterate the policy and assess any further support required in ensuring the above policy is followed in the future.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the case and work with Whittington NHS Trust to improve wound-care planning and visit-frequency decisions.
Verbatim wording from the response “Whittington NHS Trust currently provide the specialist tissue viability service for complex wounds to Camden residents and were directly involved in the care delivered to Mr Pearce. As the specialist service, they advise our district nursing teams on the wound care plan and frequency of visits. We are therefore sharing, and working together, with the Whittington NHS Trust in the learning from this case.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce secure sharing of photographs and other information about deteriorating wounds with specialist services and GPs during escalation.
Verbatim wording from the response “Due to the GPs using a different recording system (EMIS), the GP would not automatically be able to access the photographs. We recognise that it is not practical or necessary to share all photographs of wounds automatically with every GP. As part of the escalation where a patient’s condition is seen to be deteriorating, the requirement for sharing information, including photographs, is expected and would take place via secure email. This has been reinforced to our staff as part of the meeting in March and will be again reinforced at the follow up session in May.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatic sharing of all wound photographs with every GP is not considered practical or necessary; photographs will be shared during deterioration escalation.
Verbatim wording from the response “Photographic evidence was regularly taken and consent to photography was recorded with all photographs being uploaded to the clinical recording system (Systmone). The process already in place ensures that any photographs can be reviewed by the Whittington NHS Trust who currently provides the specialist tissue viability service to Camden residents and were involved in the care delivered. As mentioned above, we are working with the Whittington to address the learning from this case and are due to meet with them on 9th May as highlighted above.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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23 Mar 2016 Alwyn Ann Head · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to record meaningful nursing information about dressing and wound condition View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
The Trust
Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.
View source
The Trust
Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.
View source
The Trust
Review wound-care documentation, care plans and wound-assessment standards.
View source
The Trust
Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.
View source
The Trust
Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.
View source See 2 more actions
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AI-generated summary
Alwyn Ann Head · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record meaningful nursing information about dressing and wound condition
Wider context from the report “(5) Entries in the nursing notes relating to dressing and wound were meaningless and would not assist a determination of whether there was deterioration in the wound
” Source location Alwyn Ann Head · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.
Verbatim wording from the response “• The new documentation will be incorporated into a new nursing patient assessment / care planning document which is due to be implemented in July 2016.” Source location A-head-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.
Verbatim wording from the response “We are updating our tissue viability policy and associated standard operating procedures (SOPs) to include NICE guidance and standards for post-operative surgical wound management.” Source location A-head-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review wound-care documentation, care plans and wound-assessment standards.
Verbatim wording from the response “Wound care documentation, care plans and wound assessment standards have all been reviewed. The wound care documentation will be incorporated into the new nursing assessment / care planning document in July 2016.” Source location A-head-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.
Verbatim wording from the response “The documentation and standards will be presented to the Trust Patient Safety Group and the Nursing & Midwifery Quality Forum. Directorate representatives will be responsible for cascading the information through their Directorate.” Source location A-head-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.
Verbatim wording from the response “Compliance with the policies and SOPs will be monitored as part of our established assurance audits. Results of audits are presented at Patient Safety Group which has responsibility for monitoring compliance in this area and the Nursing & Midwifery Quality Forum.” Source location A-head-Response
Open published response
17 Nov 2014 Mrs Gladys Smith · Prevention of Future Deaths report West Yorkshire (East)
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Concerns raised 1
Failure to fully record wound dimensions and presenting features on each District Nurse visit View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mrs Gladys Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to fully record wound dimensions and presenting features on each District Nurse visit
Wider context from the report “(a) Members of the District Nursing Team who attended upon Mrs Smith did not, upon each visit, fully record and document the dimensions and presenting features of the wound . In the circumstances, the Trust should ensure District Nurses do record and document all bruises and/or wounds, in particular the dimensions of the same together with a detailed description as to all presenting features;
” Source location Mrs Gladys Smith · Prevention of Future Deaths report
Open source report
17 Jun 2014 AUDREY VERA GARLAND · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Failure to arrange District Nurse attendance to redress the legs View source Failure by the District Nursing service to treat necrotic ulcers appropriately View source Failure by the District Nursing service to appreciate necrotic ulcers View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Blackpool Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Blackpool Teaching Hospitals NHS Foundation Trust
Provide daily rotational joint clinical supervision and focused senior-nurse support for leg-ulcer and wound-care management.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Improve team referral processes for tissue-viability support in complex wound management.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Conduct daily face-to-face clinical handovers identifying high-risk complex patients and required clinical actions.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Operate performance-management systems with accountability, joint visits, reflective practice and development plans for substandard clinical performance.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Embed joint wound-review visits with tissue-viability specialists and general practitioners for patients with deteriorating wounds.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Monitor wound measurement and documentation of progress or deterioration against best-practice standards.
View source See 3 more actions
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AI-generated summary
AUDREY VERA GARLAND · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange District Nurse attendance to redress the legs
Wider context from the report “4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs .
” Source location AUDREY VERA GARLAND · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure by the District Nursing service to treat necrotic ulcers appropriately
Wider context from the report “2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering.
” Source location AUDREY VERA GARLAND · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure by the District Nursing service to appreciate necrotic ulcers
Wider context from the report “2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering.
” Source location AUDREY VERA GARLAND · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide daily rotational joint clinical supervision and focused senior-nurse support for leg-ulcer and wound-care management.
Verbatim wording from the response “Clinical supervision has been strengthened, specifically in relation to the management of leg ulcers. Supervision – in the form of joint visits with a senior nurse is happening daily on a rotational basis with individual members of the team. This is to support the changes in practice required and to ensure good practice is embedded. Individual nurses are also having more focused support by a senior nurse in the management of wound care and how to manage wound infection.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve team referral processes for tissue-viability support in complex wound management.
Verbatim wording from the response “The team has an improved understanding of the referral processes to secure Tissue Viability Advisor support in relation to complex wound management. In line with best practice standards, the measurement of wounds and documenting progress or deterioration are now being monitored robustly by the team.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily face-to-face clinical handovers identifying high-risk complex patients and required clinical actions.
Verbatim wording from the response “A daily face to face clinical handover of care is in place with high risk complex patients being identified and clinical discussions held in order that all members of the team are aware of the risks and the actions required to support good clinical care and improvement.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate performance-management systems with accountability, joint visits, reflective practice and development plans for substandard clinical performance.
Verbatim wording from the response “Performance management systems are now in place with individuals being called to account when their clinical practice fails to meet the required standard. This includes joint visits, reflective practice” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed joint wound-review visits with tissue-viability specialists and general practitioners for patients with deteriorating wounds.
Verbatim wording from the response “Any ulcer that fails to improve or deteriorates and there is an issue of noncompliance is highlighted using the organisation’s untoward incident system. Joint visits with other health care professionals such as the Specialist Tissue Viability Advisor and General Practitioners to review patients with deteriorating wounds are now embedded into practice within the team.” Source location 2014-0271-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor wound measurement and documentation of progress or deterioration against best-practice standards.
Verbatim wording from the response “The team has an improved understanding of the referral processes to secure Tissue Viability Advisor support in relation to complex wound management. In line with best practice standards, the measurement of wounds and documenting progress or deterioration are now being monitored robustly by the team.” Source location 2014-0271-Response
Open published response
29 Sep 2013 Dorothy Townley · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of District Nurses and the GP to communicate and coordinate wound care visits View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Dorothy Townley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of District Nurses and the GP to communicate and coordinate wound care visits
Wider context from the report “1. There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased’s condition was and what was required on visits. There was no consideration given to carrying out joint visits, no communication as to how Mrs Townley’s wound could be examined if there were no dressings available.
” Source location Dorothy Townley · Prevention of Future Deaths report
Open source report
7 Aug 2013 Jean Miller · Prevention of Future Deaths report Manchester (West)
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Concerns raised 1
Failure to involve tissue viability specialists when needed View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jean Miller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to involve tissue viability specialists when needed
Wider context from the report “1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s
” Source location Jean Miller · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.