Mr. Thomas Jenkins · Prevention of Future Deaths report

On the 15th August, 2014 an investigation was commenced into the death of Mr. Thomas Jenkins.
The investigation concluded at the end of the inquest on the 12th December 2014. The medical cause of death was 1a. Sepsis; 1b. Infected chronic pressure sore on right heel; and 1c. Cerebrovascular accident. The conclusion of the inquest was a narrative determination.

Narrative Conclusion:

Mr. Thomas Jenkins, 85 years old, died on 8th August 2014 on Ward 12 of the Royal Glamorgan Hospital, Wales after developing a pressure ulcer whilst in the care of the Ysbyty Cwm Rhondda Hospital following a cerebral vascular accident. Mr. Jenkins was further diagnosed as suffering from cancer and his prognosis was poor. Treatment of the pressure sore failed, the ulcer was covered, became MRSA infected and was the likely source of sepsis which led to Mr. Jenkins' death.

Mr. Thomas Jenkins suffered a cerebral vascular accident and was admitted to the Royal Glamorgan Hospital on 27.12.13. He was transferred for rehabilitation to Ward C3, Ysbyty Cwm Rhondda on 04.02.14. He developed a pressure sore on his right heel which was first noted on 11.04.14. At about this time he was diagnosed as MRSA positive at his PEG site, eyes and later his pressure sore wound. His pressure sore increased in severity from grade to 2 to a grade 3/4. He developed a further pressure sore on his right ankle and a left leg lesion. Maggot therapy was applied to his right heel wound and in this deteriorating condition he was transferred to a nursing home only to be re-admitted to the Royal Glamorgan Hospital within the week. He died 5 days later of sepsis.

(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14.

(2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched.