27 Oct 2023 Gerald Roy Cruse · Prevention of Future Deaths report Avon
View report summary
Concerns raised 7 Insufficient specialist medical capacity for timely and proactive care of older hospital patients View source Inadequate ambulance staff training in recognising and dealing with patients who have fallen View source Failure of ambulance staff to recognise falls risk and initiate further action View source Failure to identify and apply learning from falls-related incidents View source Failure to complete falls risk assessments in accordance with JRCALC guidelines View source Lack of clear guidelines for holistic management of older hospital patients View source Hospital falls causing fatal injuries View source See 4 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.
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AI-generated summary
Gerald Roy Cruse · 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
Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.
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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report “(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue.
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate ambulance staff training in recognising and dealing with patients who have fallen
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance staff to recognise falls risk and initiate further action
Wider context from the report “(5) The other two ambulance staff did not seem to understand that Mr Cruse was a falls risk , they did not consider that he was at a greater risk of falls and did not consider that any further action should have been considered or taken .
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and apply learning from falls-related incidents
Wider context from the report “(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future . Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or falls.
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments in accordance with JRCALC guidelines
Wider context from the report “(4) The paramedic working within the cohort area did not complete a falls risk assessment in accordance with the JRCALC guidelines following the admission of a patient who had just had a fall at home.
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidelines for holistic management of older hospital patients
Wider context from the report “(2) There are currently no clear guidelines as to how these patients should best be managed and there remains a serious risk that the care they receive is not holistic .
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Hospital falls causing fatal injuries
Wider context from the report “(3) Patients falling in hospitals and sustaining injuries which lead to their death remains a matter of grave concern.
” Open source report
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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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 Hospitals Bath NHS Foundation Trust; 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement actions to improve documentation-audit compliance to 95%.
Verbatim wording from the response “A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.
Verbatim wording from the response “Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot a bespoke tissue-viability monitoring tool capturing patient experience, outcomes and documentation compliance.
Verbatim wording from the response “A bespoke Tissue Viability monitoring tool has been adapted from another Trust. The tool is being piloted which aims to capture patient experience and outcomes in addition to compliance with documentation. The documentation audits are demonstrating compliance of greater than 88% and actions are in place to achieve 95%.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.
Verbatim wording from the response “The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
Open published response
12 Feb 2016 Mr. Terence Brooks · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of a procedure for investigating the cause of Legionella infection View source Failure to correctly interpret microbiological water-sample results and testing limitations 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
Mr. Terence Brooks · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr. Terence Brooks, who was being treated for acute myeloid leukaemia, developed Legionella pneumophila pneumonia and died on 23 July 2015. The report raised concerns that the hospital misinterpreted microbiological testing, conducted its investigation on a false premise, and had no procedure for investigating the cause of a Legionella infection.
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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for investigating the cause of Legionella infection
Wider context from the report “(4) The hospital, although responding promptly to the infection, had no procedure in place detailing how the investigation of the cause of a legionella infection should be undertaken .
(5) The hospital should put in place an approved procedure for the investigation of any future outbreaks of Legionella infection should they occur. This procedure should describe and define clearly inter alia the nature, limitations and interpretation of the results of any microbiological testing undertaken.
(6) The responsibility for putting such a procedure in place should be that of the Director of Infection Prevention and Control who, in drafting the procedure, should seek the support and guidance of appropriate professionals including Public Health England and the Health Safety Executive.
” 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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret microbiological water-sample results and testing limitations
Wider context from the report “(1) Those who conducted the investigation and root cause analysis on the part of the hospital did not appreciate that notwithstanding the absence of the specific subgroup of Legionella serotype 1 in the water samples from the ward as compared to samples from the deceased that this was not conclusive as to the ward not being the source of the infection .
(2) There was a lack of understanding on the part of the hospital as to how to interpret the results of the microbiological analysis of the water samples and the limitations of testing including the meaning of any results obtained, the reliability which may be placed on those results and any conclusions which may be drawn from those results.
(3) As a result of this lack of understanding the hospital misinterpreted the results and conducted their investigation and root cause analysis on a false premise which led them to conclude incorrectly that the William Budd ward was not the source of the Legionella infection.
” Open source report
19 Jun 2015 Elizabeth Godwin · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Failure to gather information from family and others involved in mental health assessments View source Failure to communicate and acknowledge transfers of patient care between agencies View source Failure to share mental health assessment information with other agencies involved in patient care View source Failure to assess, record and monitor the urgency of mental health assessments View source Failure to assign responsibility for patient care, mental health assessment and resulting treatment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Godwin · 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 Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.
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 Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to gather information from family and others involved in mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment .
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and acknowledge transfers of patient care between agencies
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail .
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health assessment information with other agencies involved in patient care
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient .
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess, record and monitor the urgency of mental health assessments
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored .
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it.
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal United Hospitals Bath NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for patient care, mental health assessment and resulting treatment
Wider context from the report “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS:
a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment.
b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.
c) As to how that information is shared with other agencies involved in the care of that patient.
d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it .
e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail.
I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver teaching sessions to improve communication with carers and patients and address barriers to family involvement.
Verbatim wording from the response “The Emergency Department continues to raise awareness of the importance of family involvement and relatives’ valuable knowledge of the patient’s wider situation. Teaching sessions, including seven one hour sessions delivered by the clinical psychologist on removing the obstacles to communication with carers and patients, have been delivered.” Source location 2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the mental health assessment matrix so similar self-harm presentations trigger amber-risk classification and mental health assessment before Emergency Department discharge.
Verbatim wording from the response “A retrospective review has confirmed that Mrs Godwin was correctly assessed, utilising the Mental Health Assessment Matrix available at the time, as being of low risk, the amendment to the Matrix ensures that future patients, who present with a similar history to that of Mrs Godwin, would flag as an “amber” risk and would receive an assessment by a mental health professional before leaving the Emergency Department.” Source location 2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add space to the self-harm proforma to record next-of-kin details, relationship and the patient’s contact wishes.
Verbatim wording from the response “In addition, there is an allocated space on the self-harm proforma for information about the patient’s next of kin, their relationship and the patient’s wishes in relation to whether they should be contacted.” Source location 2015-0233-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations