Carol Anne JENNINGS · Prevention of Future Deaths report

On 06/02/2019, I commenced an investigation into the death of Carol Anne JENNINGS aged 79. The investigation concluded at the end of the inquest on 01/08/2019. The conclusion of the inquest was:
Natural causes. The medical cause of death:

1a Septicaemia
1b Infected Leg Ulcers, Hospital Acquired Pneumonia
1c
I1 Chronic Kidney Disease

Mrs Jennings had a number of comorbidities including lymphedema, bilateral venous leg ulcers and chronic liver disease. She had several admissions to hospital due to infections. Mrs Jennings was admitted to Queen Elizabeth Hospital on 10 January 2019 due to high potassium levels. Mrs Jennings was referred to the Tissue Viability Nurse on 12 January 2019 but was not seen. She was started on antibiotics on 15 January 2019 and considered for discharge on 18 January 2019 but then remained in hospital. On 21 January 2019, Mrs Jennings legs were examined and considered to have infected leg ulcers and IV antibiotics started. She was reviewed on 23 January 2019 and no infection of the ulcers was noted. Mrs Jennings' condition deteriorated, and she was started on end of life care on 25 January 2019 and she died on 31 January 2019.

1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented.

2. The evidence revealed a lack of and/or inadequate record keeping. Mrs Jennings was admitted to hospital on 10 January 2019 and there is no detailed record describing the wound until 21 January 2019 and no measurement of the wound until 23 January 2019. There are no photographs of the wound. A wound assessment form was not completed. At the resumed inquest no steps had been taken to ensure full and proper record keeping.