Mr Philip John Powell · Prevention of Future Deaths report

On the 20 August 2017, I commenced an investigation into the death of Mr Philip John Powell. The investigation concluded at the end of the inquest on 30 November 2017.

The conclusion of the inquest was a short narrative conclusion of: Mr Powell Died after developing sepsis when a pressure sore became infected and deteriorated rapidly from a grade 3 to grade 4.

The cause of death was:

1a Sepsis and Bronchopneumonia
1b Infected Sacral Pressure Sore and Buttock Abscess

i) Mr Powell was an 83 year old gentleman who had a medical history including Parkinson’s disease, dementia and history of previous strokes.

ii) He lived at home and was cared for by his family with support of Community nurses.

iii) In July 2017 he started to develop an uncategorised stage 3 pressure ulcer and moisture lesion.

iv) He was reviewed by a tissue viability nurse on the 18 July 2017 and Debrisoft which is anti-bacterial and used in the treatment of wounds wasn’t available at the time and the nurse placed a request for more supplies.

v) No Debrisoft was in fact ordered. The pressure ulcer was then cleaned and dressed and managed with Flaminal Hydro and allevyn instead.

vi) By the 4 August there were now clear signs of infection and the ulcer had become malodorous and inflamed.

vii) By the 7 August the ulcer had deteriorated rapidly and he was admitted to Russells Hall Hospital where a 7cm cavity was identified and suspected sepsis.

viii) Despite further treatment his condition continued to decline and sadly he died on the 16 August 2017 after developing sepsis and bronchopneumonia due to the infected pressure sore.

1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound.

2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility.