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Investigation and inquest
On 21st January 2019 I commenced an investigation into the death of Arnold Fletcher Ward. The investigation concluded on the 4th December 2019 and the conclusion was one of Narrative: Died from natural causes exacerbated by the complications of a grade four pressure sore, not escalated to the Tissue Viability Team when it showed clear signs of deterioration.
The medical cause of death was 1a) Acute Myocardial Infarction; 1b) Heart Failure; II) Chronic Sacral Osteomyelitis secondary to a grade four pressure ulcer, previous Cerebrovascular Infarctions, Hospital Acquired Pneumonia
Circumstances of the death
Arnold Fletcher Ward was at high risk of pressure ulcers. He was resident at Fernlea Nursing Home. On 25th October 2018 a request was sent for Tissue Viability Nursing Team (TVN) input because he had a developing sacral pressure ulcer. No response was received and there was no follow up by the home until a further request was made on 19th December 2018. In the intervening period, it was deteriorating with an odour being present from November 2018. No clear records or photographs were taken to track the deterioration. On 21st December a Tissue Viability Nurse identified it as a grade 4 pressure ulcer
and put an immediate plan in place. On 24th December an x-ray arranged by the Tissue Viability Nurse identified osteomyelitis and he was admitted to Stepping Hill Hospital, and treated. On 21st January 2019 whilst an inpatient, he died from a myocardial infarction.
Coroner’s concerns
The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
Information checked against the published report and official responses