William Gordon Tolen · Prevention of Future Deaths report

On 7th March 2015 I commenced an investigation into the death of William Gordon Tolen do 12th January 1933. The investigation concluded on the 14th October 2015 and the conclusion was one of Natural Causes. The medical cause of death was 1a Septicaemia 1b Cellulitis and 11 Coronary Artery Atheroma.

Mr Tolen was living at Shawe Lodge from the 29th January 2015. On the 10th February it was noted that he had a problem with his legs and the GP attended and cream was prescribed. Thereafter it was also noted that he had a problem with the nail on his left great toe. The podiatrist attended and , inter alia, she removed the toe-nail which she stated was already detached from the toe. This procedure was carried out in the sitting room area of the home. Mr Tolen went on to develop cellulitis in his legs, although this was not apparently directly linked to the removal of the nail.

1. The quality of note recording and keeping at the home fell a very long way short of what might be considered satisfactory. The effect of this was that the member of staff giving evidence was unable to confirm many facts because they were simply not recorded either properly or at all.(Shawe Lodge)

2. The need for the attendance of a podiatrist was, or should have been apparent to the staff at the home, and yet they allowed 5 days to pass without ensuring that their messages had been received, hence there was a delay before Mr Tolen was seen and treated.(Shawe Lodge)

3. The witness from Shawe Lodge confirmed in evidence that the staff did not have any training in relation to dealing with this type of matter and that the nurses were not trained as to the fact that they could and should contact the Clinical manager in such cases.

4. Following this death, there has been no form of investigation by Shawe Lodge to review procedure, training or protocols within the home. (Shawe Lodge)

5. The notes at Shawe Lodge indicated that the nail had been removed from the “right” great toe when in fact it was the left. This was apparently due to a misinterpretation of an abbreviation in those notes. (Shawe Lodge)

6. The details kept in the daily “Diary” at the home were grossly inadequate, an example being “chase up podiatry (sic) for William” on the 19th February. He was known as Gordon. No-one appears to have pursued this or noted that the podiatrist did not attend the 24th February, thereby the whole system of notes being kept in a diary, in a separate individual note file, in MDT visits book and in a GP visits book appears inevitably to lead to confusion.(Shawe Lodge)

7. The Podiatrist attended and was left with the patient in the sitting room. The Shawe Lodge staff did not remain and did not offer to assist with his removal to a more suitable location for the procedure to take place. (Shawe Lodge)

8. The podiatrist carried out a procedure in the sitting room. She had to remove food debris and other detritus from around Mr Tolen’s feet before she could put down plastic sheets. This practice rendered both Mr Tolen and other residents at risk of infection and it was wholly inappropriate to carry out such a procedure in this way████████

9. Extremely late in the inquest hearing, I was informed by the attending staff from Shawe Lodge, that Mr Tolen was subject to a D.O.L.S order when he was resident there. This information, which subsequently proved to be erroneous, could have been of vital importance.(Shawe Lodge)