Kenneth George Willard KING · Prevention of Future Deaths report

On 20 November 2023 I commenced an investigation into the death of Kenneth George Willard KING aged 76. The investigation concluded at the end of the inquest on 26 November 2024.

The medical cause of death was:
1a) Septic Shock
1b) Bilateral Leg Cellulitis
1c)
2) Type Two Diabetes Mellitus, Hypertension

The conclusion of the inquest was:
Mr King died from septic shock due to bilateral leg cellulitis. His wounds were not always dressed in accordance with the recommended time scales.

Mr King had a significant medical history. He was referred to the Community Nursing Team in June 2023 due to a wound on his right ankle. Mr King was referred in July 2023 when he had three wound sites. He was seen and continued to receive assessment and dressings to his wounds in the community. At various times there were delays in Mr King being seen in accordance with recommendations sometimes by five or six days. Mr King was at times prescribed antibiotics.
On 10 October 2023 blood tests were taken and Mr King’s inflammatory markers were significantly elevated. He attended hospital but then self-discharged. He returned to hospital the next day and was admitted. Following intravenous antibiotics he was discharged to Ambulatory care on 14 October 2023 and returned to hospital on a daily basis for intravenous antibiotics until 21 October 2023, (not attending on 20 October 2023) when he was discharged to community care with oral antibiotics for five days. Mr King was not referred to the community nursing team.
An urgent visit by community nursing was requested on 27 October 2023 when Mr King had signs of infection.
On 28 October 2023 Mr King was triaged and seen that day and his dressings were changed.
Mr King was seen on 31 October and on 5 November 2023 when his dressings were changed.
Swabs were taken on 8 November 2023 when a huge amount of strike through was noted on the left leg and a moderate amount of exudue green in colour present on the right leg. Evidence was heard there was a mild malodor.
Mr King’s dressings were changed on the morning of 10 November 2023. Evidence was heard there was no malodor and no sign of infection on this occasion neither of which is referred to in the written records. A referral was made for increased visits. Later that day Mr King was admitted to Norfolk and Norwich University Hospital with cellulitis of both legs, being generally unwell and confused. Mr King’s condition continued to deteriorate and he died on 12 November 2023 from septic shock due to bilateral leg cellulitis.

NCHC have taken action and put in place many steps to prevent future deaths. However, I do have two ongoing concerns as follows:

1. Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP.
No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the attending practitioner relies on general conversation carried out at their attendance to help form a view as to whether observations are required to be taken.
It was accepted in evidence that the decision to perform observations relies on the clinical judgment of the relevant clinician, which is a subjective decision which may be exercised incorrectly and at variance with other clinicians.
Different clinicians carry out visits in the community and so have no overall view of a patient's presentation and any deterioration. Written records are available but evidence was heard that in this case, on the last visit, the record of the previous attendance was looked at and no history prior to that.
Evidence was heard that Health Care Practitioners may have limited clinical training and rely on instructions and advice from trained nurses.
In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked.

2. Mr King died a year ago and although there is a training programme which is being devised and rolled out it is not expected to be in place for a further eighteen months. The policy to prevent bank staff applying for roles when they have not undergone the required training is not yet in place.