24 Jul 2023 Alan Christopher NIPPARD · Prevention of Future Deaths report Avon
View report summary
Concerns raised 15 Failure to perform accurate daily skin assessments View source Failure to use appropriate sliding sheets for repositioning View source Failure to identify pressure sore risk through screening View source Delays in completing initial pressure sore risk assessments View source Failure of nursing staff to detect and manage new pressure sores through daily checks View source Delays in providing pressure-relieving mattresses View source Failure to weigh patients to support oedema management View source Failure to provide structured repositioning and offloading of pressure areas View source Failure to complete weekly reassessment of high pressure sore risk View source Failure to provide heel-protective repose boots View source Failure to complete the SSKIN pressure sore prevention bundle adequately View source Failure to provide regular continence checks, toileting and personal care View source Failure to provide seated pressure relief View source Inadequate recording and categorisation of pressure damage on body maps View source Poor completion of fluid balance charts View source See 12 more concerns
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AI-generated summary
Alan Christopher NIPPARD · 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
Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to perform accurate daily skin assessments
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t .
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate sliding sheets for repositioning
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him .
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify pressure sore risk through screening
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong ; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing , in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in completing initial pressure sore risk assessments
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been .
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission , (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to detect and manage new pressure sores through daily checks
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks . In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in providing pressure-relieving mattresses
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress .
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to weigh patients to support oedema management
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema .
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide structured repositioning and offloading of pressure areas
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all . He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all .
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete weekly reassessment of high pressure sore risk
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved .
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide heel-protective repose boots
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all .
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the SSKIN pressure sore prevention bundle adequately
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed .
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular continence checks, toileting and personal care
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort . She could not see this was achieved at all . The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable .
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide seated pressure relief
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly .
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording and categorisation of pressure damage on body maps
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor completion of fluid balance charts
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort. She could not see this was achieved at all. The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable.
• Fluid balance charts were poorly completed .
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Open source report
19 Apr 2023 Elizabeth Mavis HUTCHINS · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Unavailability of an acute cardiac syndrome specialist nurse practitioner role View source Lack of a hospital at night team for managing and coordinating night-time clinical calls and tasks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Elizabeth Mavis HUTCHINS · 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
Elizabeth Mavis HUTCHINS died at Royal United Hospital, Bath, on 23 January 2022 after being admitted following a fall and broken arm. She suffered myocardial ischaemia and injury that was not treated or managed, and outstanding concerns included the absence of a hospital at night team and an acute cardiac syndrome specialist nurse practitioner role.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an acute cardiac syndrome specialist nurse practitioner role
Wider context from the report “I was told that there have been a number of changes following this death at the RUH. However that there were two areas which remain outstanding:
(1) The hospital at night team, to assist with management of the hospital at night, take calls from wards, log and triage the calls, coordinate the night team, send clinicians tasks – this is still to be put into place, funding has not been secured for this.
(2) The acute cardiac syndrome (ACS) specialist nurse practitioner role – this is not in existence at this time which I am told would be an excellent compliment for the teams and support staff during the daytime hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a hospital at night team for managing and coordinating night-time clinical calls and tasks
Wider context from the report “I was told that there have been a number of changes following this death at the RUH. However that there were two areas which remain outstanding:
(1) The hospital at night team, to assist with management of the hospital at night, take calls from wards, log and triage the calls, coordinate the night team, send clinicians tasks – this is still to be put into place , funding has not been secured for this.
(2) The acute cardiac syndrome (ACS) specialist nurse practitioner role – this is not in existence at this time which I am told would be an excellent compliment for the teams and support staff during the daytime hours.
” Open source report
1 Apr 2019 Alexander Frederick Richard GREEN · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Failure of handovers to support effective communication and challenge View source Failure to apply the NICE head injury guideline before attributing depressed consciousness to intoxication View source Failure to recognise and mitigate bias when assessing possible intoxication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alexander Frederick Richard GREEN · 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
Alexander Green died at Southmead Hospital on 3 October 2017 after falling while out socialising and subsequently being found in the road. He was initially treated as intoxicated, and his head injury was not diagnosed until he suffered a respiratory collapse; the report identifies concerns about ineffective handover and communication, failure to apply head-injury guidance, and assumptions that intoxication explained his condition.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of handovers to support effective communication and challenge
Wider context from the report “1. The handover at around 8am resulted in a failure to challenge and communicate effectively .
Handovers need to be considered across the whole of the trust not just the emergency department to ensure they are appropriate and effective .
The reason I include this as a trust wide matter of concern is that I have recently dealt with another case where there were failures in the handover on another ward at the Royal United Hospital.
I have been advised that other hospitals use the SBAR tool at handovers to assist in communication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the NICE head injury guideline before attributing depressed consciousness to intoxication
Wider context from the report “2. The NICE guideline for head injury was not considered appropriate for use in this case when it is clearly designed for exactly this case – you ascribe depressed conscious levels to intoxication only after a significant brain injury has been excluded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and mitigate bias when assessing possible intoxication
Wider context from the report “3. There was an assumption by everyone managing Alex that he was intoxicated when in fact he had a significant head injury ; SWAST I am told have developed training in relation to bias (and intoxication is included in that) .
” Open source report
13 Mar 2019 Marcie Joan TADMAN · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of second consultant review on the paediatric ward View source Unavailability of a paediatric High Dependency Unit facility View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Marcie Joan TADMAN · 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
Marcie Joan Tadman died on 5 December 2017 at Royal United Hospital after admission with pneumonia and parapneumonic effusion. The report describes failures to recognise and manage sepsis, follow hospital procedures and protocols, communicate effectively, conduct proactive reviews, and make appropriate decisions. It also identifies the absence of a paediatric high dependency unit at the hospital as a concern.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of second consultant review on the paediatric ward
Wider context from the report “• I heard from the independent expert Dr. Ninis that the only opportunity for Marcie to be picked up with fresh eyes would have been at another ward.
I understand that this would be an opportunity for a Consultant to take a step back and review the notes, charts, PEWS and results; examine the patient and to make a plan. In Marcie’s case everyone agreed that all of the information was there in her records but no one carried out this exercise ; there was and is no second word round on the paediatric ward at the RUH .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a paediatric High Dependency Unit facility
Wider context from the report “• I was also made aware at the inquest that there is no High Dependency Unit (HDU) facility on the RUH paediatric ward for children in their care and this was something that they were hoping to provide but needed to create a business case to the Accountable Offices for BANES CCG for this.
In Marcie’s case she should/would have been placed in such a unit had one been at the RUH at the time.
” Open source report
28 Jan 2019 Dennis Peter Alfred Warner · Prevention of Future Deaths report West London
View report summary
Concerns raised 5 Failure to provide discharge information in a form the patient could comprehend and retain View source Use of suboptimal chest X-ray imaging after chest injury View source Lack of available appropriate examination capacity in the emergency department View source Failure of the contact and recall process to communicate effectively with the patient or GP View source Delays in senior clinician review of reported chest X-rays View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dennis Peter Alfred Warner · 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
Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge information in a form the patient could comprehend and retain
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital . (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Use of suboptimal chest X-ray imaging after chest injury
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed . I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury (4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of available appropriate examination capacity in the emergency department
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the contact and recall process to communicate effectively with the patient or GP
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician . An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered . A letter was sent which was described as misleading . Consequently the efforts made to contact and recall the patient were inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in senior clinician review of reported chest X-rays
Wider context from the report “(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate.
” Open source report
13 Aug 2014 Dorothy Joan ROBINSON · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to implement a Trust-wide system preventing prescription errors due to intolerance, reaction or allergy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dorothy Joan ROBINSON · 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 Joan Robinson developed pneumonitis after Busulphan was prescribed despite a previous recorded intolerance and died after being admitted to hospital severely unwell. The principal concern was the continuing risk of prescribing errors because previous drug intolerances, reactions or allergies may not be adequately identified across the Trust.
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. The report was sent to Royal United Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a Trust-wide system preventing prescription errors due to intolerance, reaction or allergy
Wider context from the report “During the inquest I heard evidence that there remains a risk of a prescribing error despite the steps taken by RUH to date . I have been advised that there is only one way to help prevent this and that is through the electronic prescribing system referred to in the Action Plan to the Root Cause Analysis . I was not told an exact date when the system will be introduced only that there was an understanding that it may take up to two years . I would like to receive reassurance from the RUH as to the exact steps that are being taken in relation to installing this system or indeed any other system which can help prevent a prescription error.
I was advised that the millennium system is not proposed to be used in this way
Therefore in summary please advise of the steps planned to be taken to prevent a prescription error across the whole of the Trust in all areas of medicine due to a previous intolerance/reaction/allergy .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations