Doreen England · Prevention of Future Deaths report

On 9th October 2014 I commenced an investigation into the death of Doreen England. The investigation concluded at the end of the inquest on 21st July 2015. The conclusion of the inquest was a narrative:

The deceased died from an infected grade 4 pressure sore which developed during her admission from 20/7/14. There was a gross failure to prepare and put a care plan in place to monitor and prevent pressure sore formation following a waterlow score of 17 indicating high risk on 20/7/14. There was an overall lack of knowledge on the ward of how pressure sores formed and how they could be prevented. Her death was contributed to by neglect.

The deceased was an 81 year old lady who suffered from vascular dementia. Her family were unable to care for her at home due to deterioration in her condition. She was unsettled and screaming out. She was initially admitted to an EMI residential home who were unable to care for her needs. She went to A&E at Good Hope hospital on 19/07/14. They arranged a mental health assessment which resulted in her being admitted to Rosemary Suite at the Juniper Centre (part of Birmingham and Solihull Mental Health Trust) on 20/7/14. On admission a waterlow score was undertaken which confirmed a result of 17 indicating she was at high risk of pressure sore formation. Despite this risk no care plan was prepared, and no care provided to prevent pressure sores occurring. On 23/7/14 blood test results revealed a raised white cell count and CRP indicating possible infection – these results were not followed up or repeated. On 24/7/14 her sacrum was noted to be red. On 25/7/14 a further waterlow score was undertaken which showed a result of 19. A care plan was prepared including a 2 hourly turning chart but this was not commenced. By the evening on 27/7/14 her sacrum was described as having a very bad sore and a 2 hourly turning chart was put in place. From 28/7/14 she was nursed in bed to relieve pressure on her sacrum. On 29/7/14 she became systemically unwell and was prescribed antibiotics. Her condition deteriorated resulting in her admission to QEHB on 30/7/14 when a grade 3 pressure sore was diagnosed. Bu 08/08/14 she developed osteomyelitis of the sacral bone and a chest infection. The sore was graded as 4 by 11/8/14. Towards the end of August there was some improvement in her condition but she deteriorated again on 02/09/14. She deteriorated further on 17/9/14 and remained unwell until her death on 30/9/14.

(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
(2) Since these events staff confirmed at the inquest that they had still not had training on pressure sore formation and prevention.
(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
(4) Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge. This is a subject that should be covered in the RMN curriculum.