Peter Michael HARTE · Prevention of Future Deaths report

On 29 March 2021 I commenced an investigation into the death of Peter Michael HARTE. The investigation concluded at the end of the inquest. The conclusion of the inquest was Natural Causes.

The deceased was admitted into Birmingham Heartlands Hospital at 01:27 on 19/03/2021 and was diagnosed and treated for sepsis. His prognosis was poor due to his pre-existing comorbidities and it was determined that a ward-based ceiling of care was appropriate and would preserve his dignity. Sadly, his condition deteriorated despite treatment, and he died with his family at his bedside at 10:25 on 19/03/2021. Prior to admission, he was being cared for in a care home but he was difficult to manage and was non-compliant with care due to symptoms of suspected vascular dementia. During that time, his skin was monitored, but records were not kept between 14th to 18th March. Post-mortem examination revealed pressure ulcers to his buttocks and sacral area, but these occurred peri-mortem and did not cause or contribute to death. His death was due to multiple organ failure and sepsis, stemming from a bacterial skin infection causing cellulitis which sadly did not respond to treatment.

Natural Causes

Following a post mortem, the medical cause of death was determined to be:

1a Multi-organ failure / septic shock

1b Staphylococcus Aureus Septicaemia

1c Cellulitis

II Vascular insufficiency due to atherosclerosis

1. The evidence of ████████ suggested that proper skin inspections and skin monitoring were not carried out between 14th to 18th March 2021 as, had they been carried out, they would have been documented and recorded in detailed body maps.

2. The evidence of ████████ suggests that skin inspections were carried out but were not recorded. It was admitted by ████████ in evidence that there was a failure to keep proper and adequate records by staff.

3. At inquest I found that, on the balance of probabilities, inspections were carried out but observations were not recorded and records were not kept.

4. It was unclear whether this was a "one-off" incident or whether it reflected a systemic issue. On reflection, the fact that records were not taken or kept over a period of four consecutive days (as opposed to one isolated day), is indicative of a systemic issue that staff are not ensuring that their observations are correctly and adequately recorded.

5. It is clear that a failure to ensure that there is a correctly working system of record taking poses a risk of future deaths occurring, especially in the context of extremely frail and vulnerable adults/residents who in a position of dependency by virtue of their frailty or vulnerability.