Recurring concern

Inadequate district nursing wound care

First to latest report 7 Aug 2013 — 20 Aug 2025

Reports that mention this concern
17
Times this concern has been raised
23
Stated actions linked to this concern
25

What this concern includes

Includes failures of the district nursing wound-care process, including inadequate assessment or documentation, referrals, attendance frequency, dressing changes, coordination, escalation or other controls specifically required to deliver safe wound care.

What is not included
  • Excludes generic failures to record visits or clinical information that are not specifically tied to district nursing wound care.
  • Excludes general district nursing capacity or communication problems unless they directly impair wound care.
  • Excludes non-district-nursing wound care and unrelated discharge, referral or record-keeping deficiencies.

Reports and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Mary Anne FITZPATRICK · 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

    Mary Anne Fitzpatrick was discharged from hospital on 29 January 2025 and received district nursing care. A sacral pressure sore progressed from category 2 to category 4, leading to readmission on 27 February, deconditioning and her death. Concerns included the frequency and adequacy of wound dressing visits, the development and treatment of the pressure sore, and insufficient reflection by the district nursing team after her death.

    Read the report on judiciary.uk

    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 provide district nursing wound care at appropriate frequency

    Wider context from the report

    “2. The district nurses did not visit to dress the sacral wound with appropriate frequency. Sometimes they attended as planned, but sometimes they did not attend and sometimes they attended but did not change the sacral dressing. It remains unclear to me why that was so. The only explanation I was given was that they were probably “thin on the ground”. ”

    Source location

    Mary Anne FITZPATRICK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Individualise daily district-nursing visit allocations for patients’ pressure-ulcer management needs, with monthly service-lead oversight.

    Verbatim wording from the response

    “• Ensure daily visits allocations are individualised to meet the patients’ Pressure Ulcer (PU) management need by the duty manager, with monthly oversight from Service Lead.”

    Source location

    Response from Whittington Health NHS Trust
    Page 3 · response
    Published 2 September 2025

    Open published response

    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

    Include tissue-viability referrals, recommendation adherence and pressure-ulcer improvement-plan progress in quarterly audits and divisional quality review.

    Verbatim wording from the response

    “• Timely referral to Tissue Viability Nurse (TVN), adherence with TVN recommendations, and progression of pressure ulcer management improvement plan are to be built into new quarterly audit cycle, and reviewed at divisional quality meeting.”

    Source location

    Response from Whittington Health NHS Trust
    Page 3 · response
    Published 2 September 2025

    Open published response

    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

    Trial visit-allocation software in the urgent-response team to assess whether it can reduce travel time and increase visit time.

    Verbatim wording from the response

    “• A trial of visit allocation software (Docabode) is in progress in the Urgent response team and is intended to minimise travel time and maximise time for visits. If successful it will be trialled in District Nursing”

    Source location

    Response from Whittington Health NHS Trust
    Page 4 · response
    Published 2 September 2025

    Open published response

  2. Manchester South

    AI-generated summary

    George Neville Coulthard · 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

    George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limited access to tissue viability and district nursing information and support for wound care in the community

    Wider context from the report

    “4. The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However the demands across GM on TVN and DN services made this difficult to achieve. ”

    Source location

    George Neville Coulthard · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Demand across Greater Manchester tissue viability and district nursing services made improved community wound-care access difficult to achieve.

    Verbatim wording from the response

    “The evidence before the inquest was that whilst in the community prior to his final hospital admission the access to information and support, from tissue viability and district nursing teams, to care for and treat his wounds was very limited. Better access to wound care would have reduced the risk of further wound deterioration in the community and reduced the risk of him requiring inpatient care for his wounds. However, the demands across GM on TVN and DN services made this difficult to achieve.”

    Source location

    Response from GMIC
    Page 6 · response
    Published 24 September 2024

    Open published response

    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

    Limited access to community tissue viability and district nursing wound care falls outside the regulator’s remit.

    Verbatim wording from the response

    “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 5 · response
    Published 24 September 2024

    Open published response

    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

    The Secretary of State and Greater Manchester Integrated Care are considered better placed to address limited community wound care access.

    Verbatim wording from the response

    “We have considered this point and have concluded that, this regretfully sits outside of CQC remit. We believe the Secretary of State and Greater Manchester Integrated Care will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 5 · response
    Published 24 September 2024

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Stanley Cummins · 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

    Stanley Cummins, aged 84, died at home on 2 September 2022 after a heel pressure ulcer became necrotic and led to sepsis. The inquest identified concerns about failures to provide appropriate pressure relief and offloading advice, make referrals, and implement comprehensive changes to his care, with further training and protocols still described as work in progress.

    Read the report on judiciary.uk

    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 escalate pressure-wound issues to other services and professionals when needed

    Wider context from the report

    “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds. I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals. The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed. ”

    Source location

    Stanley Cummins · Prevention of Future Deaths report
    Page 2 · concerns

    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 to provide appropriate pressure-wound offloading advice and recommendations to families and carers

    Wider context from the report

    “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds. I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals. The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed. ”

    Source location

    Stanley Cummins · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Uncompleted pressure-wound safety protocols

    Wider context from the report

    “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds. I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals. The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed. ”

    Source location

    Stanley Cummins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 and update SystmOne wound assessments and care plans to include photography, heel off-loading advice and onward-referral guidance.

    Verbatim wording from the response

    “The wound assessments and care plans in SystmOne are being reviewed and updated to include photography and advice re: off-loading and onward referrals.”

    Source location

    Response from County Durham and Darlington
    Page 1 · response
    Published 6 March 2024

    Open published response

    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

    Deliver community nursing study days covering updated wound documentation, equipment, incident reporting and heel off-loading.

    Verbatim wording from the response

    “Study days have been booked for key staff in all community nursing teams for June 27th and 28th 2024. This will include the launch of the updated assessments and care plans, equipment updates, incident reporting updates and the use of heel off-loading.”

    Source location

    Response from County Durham and Darlington
    Page 1 · response
    Published 6 March 2024

    Open published response

    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

    Develop patient and carer information leaflets about heel off-loading.

    Verbatim wording from the response

    “Patient/carer information leaflets are also being developed regarding off-loading.”

    Source location

    Response from County Durham and Darlington
    Page 2 · response
    Published 6 March 2024

    Open published response

    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

    Implemented and planned measures are considered sufficient to address concerns about learning, offloading advice, and escalation.

    Verbatim wording from the response

    “We trust that the measures already implemented and those planned are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.”

    Source location

    Response from County Durham and Darlington
    Page 2 · response
    Published 6 March 2024

    Open published response

  4. Manchester South

    AI-generated summary

    Susan Wendy Bracegirdle · 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

    Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.

    Read the report on judiciary.uk

    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 upload updated images for Tissue Viability review of deteriorating pressure ulcers

    Wider context from the report

    “6. The Tissue Viability team had been asked by the District Nurses for input. This was provided remotely via access to photos taken by the District Nursing Team. Whilst it was clear that remote review could be effective it was not in this case because the review was based on an older image and an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded. This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture. ”

    Source location

    Susan Wendy Bracegirdle · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Photograph and upload every wound to the patient’s electronic record weekly.

    Verbatim wording from the response

    “All wounds are to be photographed and uploaded on to the patient’s electronic record system once per week by the District Nursing Team.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 8 · response
    Published 12 February 2024

    Open published response

    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

    It is unclear whether updated tissue-viability advice would have altered treatment, although providing an updated image would have been helpful.

    Verbatim wording from the response

    “an updated image showing a deteriorating picture in relation to the pressure ulcers was not uploaded. This was as a result of lack of joint working and effective communication. The impact was that what would have been helpful expert input from the TVN was not provided to a deteriorating picture.”

    Source location

    Response from Care Quality Commission
    Page 8 · response
    Published 12 February 2024

    Open published response

  5. Inner South London

    AI-generated summary

    Mr Locksley Burton · 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

    Mr Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

    Read the report on judiciary.uk

    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 maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”

    Source location

    Mr Locksley Burton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.

    Verbatim wording from the response

    “Throughout the pandemic ‘lockdowns’ and since, the Home has continued to engage with the regular Monthly Multi-Disciplinary Meetings. During the pandemic, these were a blend of virtual and in-person meetings. As the Home Manager for the Home, I review the Clinical Risks of each resident through our monthly Key Clinical Indicators exception reports. These include wounds and the escalation process. Mr Burton’s wound deterioration and his presentations were discussed at these meetings.”

    Source location

    Response from The Kind Care Company
    Page 3 · response
    Published 29 September 2022

    Open published response

    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 each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.

    Verbatim wording from the response

    “Throughout the pandemic ‘lockdowns’ and since, the Home has continued to engage with the regular Monthly Multi-Disciplinary Meetings. During the pandemic, these were a blend of virtual and in-person meetings. As the Home Manager for the Home, I review the Clinical Risks of each resident through our monthly Key Clinical Indicators exception reports. These include wounds and the escalation process. Mr Burton’s wound deterioration and his presentations were discussed at these meetings.”

    Source location

    Response from The Kind Care Company
    Page 3 · response
    Published 29 September 2022

    Open published response

    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

    There is no evidence that clinic attendance was less frequent than clinically indicated or reduced because of the Covid-19 pandemic.

    Verbatim wording from the response

    “Following the beginning of the first lockdown, on the 23rd March 2020, there was a reduction of patients seen by the Diabetic Foot Clinic from fifty to approximately twenty-five per day. However, there is no evidence from Silhouette (which is the Diabetic Foot Clinic’s records system) that Mr Burton was seen less frequently than clinically indicated. Mr Burton was seen, as planned on the 26th March 2020, in the Diabetic Foot Clinic. His right and left feet were treated with a plan to review in three to four weeks’ time. The review timescale was based on clinical history, observations and clinical judgement taken on the day. There is no evidence that this decision was made due to the impacts of the Covid-19 pandemic. The decision was made based on the clinical judgement of an experienced podiatrist who knew the patient well.”

    Source location

    Response from Kings College Hospital
    Page 1 · response
    Published 29 September 2022

    Open published response

    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

    The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.

    Verbatim wording from the response

    “As the Coroner has correctly concluded, the pandemic was the reason that the DFC reduced its attendance. The GP was made aware of this during his attendances at the Home during the relevant period. We do note however that it was a period of unprecedented uncertainty and many services, the DFC included, were running a reduced service and attempting to adapt to the changing status of contact with individuals requiring care during this period.”

    Source location

    Response from The Kind Care Company
    Page 2 · response
    Published 29 September 2022

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Jane Lesley Bruce · 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

    Jane Bruce sustained a right tibia and fibula fracture after a fall, underwent surgery, and was receiving community wound care when her condition deteriorated. She presented to hospital with features consistent with sepsis and died the following day. The principal concern was that fragmented community nursing care, lack of wound photographs, and inability to access electronic records contributed to her deterioration not being fully appreciated and delayed escalation for medical review.

    Read the report on judiciary.uk

    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 take wound photographs for continuity and reference

    Wider context from the report

    “Ms Bruce was care for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for continuity / reference to and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not. This meant that Ms Bruce’s change in condition was not fully appreciated. Leicestershire Partnership Trust have learned from this and District Nurse now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record the blood pressure, oxygen saturation levels and temperature. Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere. ”

    Source location

    Jane Lesley Bruce · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Cecilia EDWARDS · 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

    Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.

    Read the report on judiciary.uk

    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 make immediate tissue viability referrals for category 3 pressure ulcers

    Wider context from the report

    “1. On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse. However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-ordinator until 22 September 2020. ”

    Source location

    Cecilia EDWARDS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 the referral process for Tissue Viability Nursing referrals.

    Verbatim wording from the response

    “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.”

    Source location

    2021-0049-Response-from-Whittington-Hospital-Redacted
    Page 1 · response
    Published 26 February 2021

    Open published response

    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

    Revise and formally ratify Tissue Viability Nursing referral guidance, following staff consultation, with regular compliance audits.

    Verbatim wording from the response

    “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.”

    Source location

    2021-0049-Response-from-Whittington-Hospital-Redacted
    Page 1 · response
    Published 26 February 2021

    Open published response

  8. Mid Kent and Medway

    AI-generated summary

    CHRISTOPHER 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

    Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.

    Read the report on judiciary.uk

    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 make district nurse referrals for specialist wound care

    Wider context from the report

    “(5) Mr Smith has extensive leg ulcers that required specialist input. No district nurse referral was made to ensure that Mr Smith’s leg ulcers were treated. ”

    Source location

    CHRISTOPHER SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Mavis May Lawrence · 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

    Mavis May Lawrence, who had severe dementia and required full nursing care, was admitted to hospital with dehydration, deep ungradable pressure sores and a buttock abscess, and later died on 28 February 2019. The inquest concluded that she died from natural causes exacerbated by infected pressure sores. Concerns included gaps in pressure-area checks and care documentation, a pressure mattress being turned off, lack of escalation and pain-relief evidence, insufficient GP involvement, and district nurses not involving tissue viability nurses.

    Read the report on judiciary.uk

    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 of district nurses to involve Tissue Viability Nurses

    Wider context from the report

    “(8) District nurses had not involved Tissue Viability Nurses. ”

    Source location

    Mavis May Lawrence · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.

    Verbatim wording from the response

    “(8) District nurses had not involved Tissue Viability Nurses. The district nurses and assistant practitioner band 4 assistant practitioners are skilled in managing wounds; including pressure ulcers.”

    Source location

    2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
    Page 2 · response
    Published 26 November 2020

    Open published response

  10. Mid Kent and Medway

    AI-generated summary

    Dorothy June MACEY · 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 June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

    Read the report on judiciary.uk

    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 photograph leg wounds for assessment

    Wider context from the report

    “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”

    Source location

    Dorothy June MACEY · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Lack of an updated care plan for leg dressings

    Wider context from the report

    “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”

    Source location

    Dorothy June MACEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026