Jane Bullock Wilson Stables · Prevention of Future Deaths report

On 13/04/2016 I commenced an investigation into the death of Jane Bullock Wilson Stables, 70. The investigation concluded at the end of the inquest on 15 December 2016. The conclusion of the inquest was a Narrative conclusion. The cause of death was: 1a. Sepsis 1b. Pressure Ulceration of skin, 1c. Immobility from Rheumatoid Arthritis, 2. Ischaemic heart disease, frailty, malnourishment.

Mrs Stables had a long history of severe rheumatoid arthritis treatment for which was limited due to her morbid fear of hospitals to the extent that she declined to attend for consultations. The disease progressed and by the end of 2015 she was in considerable pain with contractures and had become bed bound. District nurses were visiting regularly, their visits were increased. She also had carers attending four times a day. The evidence I heard from the district nurses, tissue viability nurse and the carers was entirely consistent with regard to the extent of Mrs Stables pain and challenges this presented in providing her with care and repositioning her as required. The pain was never properly controlled and thus she was caused severe pain when care was delivered. In spite of this there was a failure on the part of the nurses and carers to effectively communicate those concerns with the General Practitioner which would have enabled further pain relief reviews to have taken place and thus the possibility of enhanced pain relief which would have more effectively managed that pain. In addition, the district nurses put in place a care plan for regular turning and that she was to be repositioned on each of the four attendances that the carers made each day. Despite this, the turns were not carried out as directed, the documentation regarding turns and repositioning is lacking and on some days there appeared to be no repositioning at all. From the 14th March to the 21st March the notes are particularly scant with regard to repositioning and turns and by the 21st March the community staff nurse was so concerned that the advice to regular turn had not been followed that she raised this again with ████████ left a note for the carers and also left repositioning charts. From that point on there was increased frequency in turns and recording of the same but the back area on the coccyx noted on the 16th March together with other pressure sores had significantly deteriorated and my conclusion is that a contributory factor was the failure to adhere to the care plan and in particular the turns required under that plan. On the 30th March Mrs stables was admitted to the Doncaster Royal Infirmary as an emergency and she passed away there on the 2nd April 2016.

(1) Ineffective communication between the nurses and general practitioner regarding ongoing significant pain levels which were impeding care provided.