Mr. Arthur Cook · Prevention of Future Deaths report

On the 21st April, 2015 I commenced an investigation into the death of Mr. Arthur Cook, 78 years old. The investigation concluded at the end of the inquest on the 3rd July, 2015. The conclusion of the inquest was ‘Death from a poorly managed MRSA infected wound’.

Mr. Arthur Cook suffered from poor circulation and was being treated by vascular surgeons for gout and necrosis of his toes leading to toe amputation. Since March 2014, he had been a patient under the care of both the Aneurin Bevin Hospital Board (AHBB) and the Cwm Taf University Health Board (CTUHB). During this period he had been admitted to the Royal Glamorgan Hospital; the Ysbyty Ystrad Fawr; and the Four Seasons Healthcare Residential Home where he was under the medical supervision of the Bryntirion Surgery, Bargoed, all of which are under the AHBB.

Mr. Cook had further periods of hospitalisation in Prince Charles Hospital which is administered by CTUHB. He was discharged from Ward 31, Ysbyty Ystrad Fawr to the Four Seasons Healthcare Residential Home on 14th January, 2015 with a chronic open wound to his right knee - an injury sustained when a patient in the Royal Glamorgan Hospital.

Whilst a resident at the Four Seasons Healthcare Residential Home, Mr. Cook developed a wound (possibly pressure ulcer) to the back of the right knee. On the 25th January 2015 the wound exudate was assessed as ++. At this time tissue viability care was sought from the ABHB and again in February 2015 but the residential home Manager was advised of the lack of availability of specialist nursing advice at that time. TVN advice was not provided until April 2015. At this time Mr. Cook was admitted to Prince Charles Hospital with an MRSA infected category 4 pressure ulcer. He failed to respond to treatment and subsequently passed away.

(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need;
(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal.
(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services.