Jean Miller · Prevention of Future Deaths report

On 3rd July 2013 I completed the Inquest into the death of Mrs Jean Miller, who died on 24th January 2013 at The Royal Bolton Hospital. The cause of Mrs Miller’s death was
1a. multi organ failure;
1b. sepsis;
1c. wound infection following elective incisional hernia repair; and
2. Atherosclerosis

The circumstances revealed in the evidence before me included the following:

1. Mrs Miller was born on 19th August 1938
2. On the 14th November 2012 she was admitted to the Royal Bolton Hospital for an incisional hernia repair operation.
3. She remained a patient at the Royal Bolton Hospital for post operative care. Her surgical wound was monitored for potential infection by the staff at the Royal Bolton Hospital.She became hypoxic and as a result her oxygen levels were monitored in addition to the wound.
4. On 8th December 2012 she was examined by ████████ who was satisfied that she was medically fit for discharge home under the care of the district nursing team.
5. The District Nursing Team began daily visits to Mrs Miller at her home address from 10th December 2012.Their role was to dress and inspect the wound daily to ensure Mrs Miller did not deteriorate and her wound healed satisfactorily.
6. However they did not baseline her wound when they commenced their care of Mrs Miller and the tissue viability team were not involved by the district nursing team in Mrs Miller’s care.
7. Concerns about a deterioration in Mrs Miller’s wound resulted in a swab being taken on 18th December 2012.
8. During their care of Mrs Miller the district nursing team carried out a number of checks on Mrs Miller to try to identify if her condition was deteriorating. However I was told that they did not take her temperature whilst caring for her.
9. The inquest was told that district nurses within the trust did not take temperatures as part of their routine care and were not expected to. The inquest was further told that the district nurses were not issued with thermometers as part of their medical kit when caring for patients.
10. One of the district nurses indicated that if she was worried a patient had a temperature she would check their forehead to see if they felt hot.
11. Mrs Miller was readmitted to the Royal Bolton Hospital on 24th December 2012 with what was described as a purulent discharge from the wound site. She received treatment at the Royal Bolton Hospital following her admission including further surgical intervention and was on the intensive care ward. She died on 24th January 2013 at the Royal Bolton Hospital.

The evidence I heard at the Inquest established that:
1. The wound was not of concern at the time of discharge from the Royal Bolton Hospital and had there been concerns Mrs Miller would not have been discharged.
2. The district nursing team were not able to fully monitor any possible deterioration of the wound in the absence of a baseline assessment
3. The specialist services of the Tissue Viability team were not accessed by the District Nursing Team
4. The basic nursing check of temperature taking using a thermometer was not carried out by the district nursing team and there was no expectation of such an action being carried out by their management team
5. District Nurses with the Pennine Trust are not issued with thermometers to assist them in the care of patients
6. The quality of the notes kept by the District Nursing Team was poor
7. There was limited communication with the GP notwithstanding the proximity of the District Nurses to the GP
8. Mrs Miller’s wound had significantly deteriorated by the time the District Nursing Team identified she could no longer be cared for at home and required readmission to hospital

1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s
2. The lack of basic equipment issued to the District Nursing Team in particular thermometers
3. Poor record keeping by the District Nursing Team
4. Poor communication by the District Nursing Team with the GP