This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 04 November 2021 I commenced an investigation into the death of Carol Ann DIVALL aged 74. The investigation concluded at the end of the inquest on 26 April 2024. The conclusion of the inquest was that:
C A Divall suffered from Alzheimer's disease for the previous 7 years before she sustained a hip fracture at home on 15th September 2022. She had been living at home and was looked after by her husband. She was admitted to the Conquest Hospital where it was repaired on 16.9.22. She was not discharged until 24.10.22 to the care of the Community Nursing Team who immediately assessed Mrs Divall as requiring end of life care. Mrs Divall died on 29.10.22 at home.
Circumstances of the death
C A Divall suffered from Alzheimer's disease for the previous 7 years before she sustained a hip fracture at home on 15th September 2022. She had been living at home and was looked after by her husband. She was admitted to the Conquest Hospital where it was repaired on 16.9.22. She was not discharged until 24.10.22 to the care of the Community Nursing Team who immediately assessed Mrs Divall as requiring end of life care. Mrs Divall died on 29.10.22 at home.
Coroner’s concerns
A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case.
B. Mrs Divall was referred to the Physiotherapy Department 2 weeks after admission but was rarely assisted with mobilisation and left to sit out in her chair for long periods. Action should have been taken to encourage Mrs Divall to mobilise more often in an attempt to rehabilitate her after her surgery.
C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary.
D. The Discharge Summary was misleading to the District Nurses who were unaware of the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did not make clear that Mrs Divall had been discharged for end of life care.
E. The RCA was insufficient and did not address all of the issues surrounding Mrs Divall's care nor did it properly address those issues it did consider.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.21
Action
Remind ward staff to offer suitable nourishing drinks before dietitian review and promote high-calorie, high-protein ward options.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Implement electronic prescribing and medicines administration to reduce missed medicines.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Conduct regular senior nurse-led audits of compliance with MUST treatment plans.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Develop and implement the 5P discharge process for communicating significant pressure damage.
Stated byEast Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 May 2024.
Action
Review the completed Trust-wide inpatient-bed audit to determine effective next steps for mattress protection.
Stated byEast Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 May 2024.
Action
Provide Saturday physiotherapy assessments for new fractured-neck-of-femur patients.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Audit the impact of electronic prescribing and medicines administration on missed medication.
Stated byEast Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 May 2024.
Action
Undertake a Trust-wide audit of MUST assessment quality and treatment evidence.
Stated byEast Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 May 2024.
Action
Develop and use a pressure-ulcer After Action Review template under the Patient Safety Incident Response Framework.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Update Dietetic Assistant competencies and provide training and support on accurate referral coding.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Increase physical therapy capacity by employing two full-time Physical Therapist Assistants.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Establish a dedicated Mouth Care Matters Lead role and deliver targeted mouthcare training.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Stated byEast Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 May 2024.
Action
Complete daily hybrid-mattress-pump checks in pilot wards and address identified equipment issues.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Maintain electronic MUST and mouthcare assessments to record and monitor patient care.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Undertake a pressure-ulcer prevention and management quality-improvement project with Tissue Viability Team support.
Stated byEast Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 May 2024.
Action
Share learning from the hybrid-mattress-pump pilot areas across the Trust.
Stated byEast Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 May 2024.
Action
Provide risk-based scheduled mouthcare reviews with electronic prompts and escalation of missed reviews.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2
Position
A failed hybrid mattress pump would ordinarily still provide sufficient protection against pressure damage, although it did not do so in this case.
Stated byEast Sussex Healthcare NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The RCA was specifically scoped to pressure ulcers, so it did not address other care concerns that were not identified during admission.
Stated byEast Sussex Healthcare NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3
1
Develop and obtain clinical-governance approval for a rapid-escalation Standard Operating Procedure for high-risk or complex patients.
Stated byEast Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 May 2024.
2
Hold bimonthly Quality Summits for Ward Matrons to reinforce communication with families and staff.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
3
Revise, publish and embed the patient-choice treatment-planning policy in relevant training.
Stated byEast Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
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Information checked against the published report and official responses