Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report

On 10th July 2010 I opened an inquest into the death of Mohammed Mozammel Chaudhury. The investigation concluded at the end of the inquest on 2nd August 2013. The medical cause of death was 1a Overwhelming sepsis 1b Chest and other infection 1c Traumatic brain injury. The conclusion of the inquest was a narrative determination.

Mohammed Chaudhury suffered multiple injuries from a traffic collision on the 7th September 2009. He was cared for in Kings College Hospital initially in ITU when he was immobile due to fractured pelvis and was at high risk of bed sores due to minimal consciousness, peripheral vascular disease, diabetes and PEG feeding. He was transferred to a step down ward without pressure sores on 27th September. There he developed a number of infected pressure sores, which were due to not being nursed on an air mattress for three weeks and insufficient turning due to shortage of nursing staff. He was transferred to a nursing home with five pressure sores between grades 2 and 4, which were septic.

(1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27th September and 9th December.

(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported.

(3) Nursing rotas for the period were not available. Some days were reported as below establishment. (8 by day and 6 by night for 31 patients of which at least a ¼ were high dependency). Not all bank shifts were filled.

(4) Although the ward has since been restructured and takes different cases, it was not possible to conclude that current staffing levels in the hospital for unconscious patients requiring regular turning were safe, as comparisons were difficult and the judgement required professional and managerial opinion.