Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report

On 28th October 2014 I commenced an investigation into the death of Janine Eugenie Pierrette KAISER. The investigation concluded at the end of the inquest on 13th July 2015. The conclusion of the inquest was that Mrs Kaiser died from significant natural disease with a contributing sacral ulcer the progress of which had been compromised by gaps in her nursing care. The cause of death was given as-
1a Lobar pneumonia.
1b Suppurative cystitis, sacral pressure ulcer and aortic stenosis, multiple myeloma, stroke.

The deceased had a history of multiple myeloma, aortic stenosis, atrial fibrillation, stroke and urinary tract infection. She was bed bound. She became resident at New Park Nursing Home, Chivelstone Grove, Trentham, Stoke on Trent in December 2013. She was on occasions non- compliant with feeding, fluid and turning regimes. She developed a sacral pressure ulcer and tissue viability nurses were involved. Her management plan was not always followed and nursing records were found to be inaccurate. On the 15th October 2014 tissue viability nurses found her pressure mattress not alternating and with the alarm turned off despite twice daily records recording it as having been checked and in order. She died at the home at 8.20pm on the 21st October 2014. The cause of death was given as lobar pneumonia, suppurative cystitis, sacral pressure ulcer, aortic
stenosis, multiple myeloma and stroke.

1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.

2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded.

3. Staff appeared inadequately trained in record keeping.

4. There was poor continuity of staff.

5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.

6. Referral to Tissue Viability nurses should have been done sooner.

7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing Home

8. The deceased was incontinent and had required cleaning before Tissue Viability Nurses were able to examine her.

9. Single agency staff investigating Adult Protections Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals.