Report evidence summary
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide two-hourly repositioning
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide accurate and complete discharge information
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to conduct a sufficient and comprehensive root cause analysis
Wider context from the report “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.
” Is this part of a recurring concern? Yes — Unreliable root cause analysis processes .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide basic nursing oral care
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Delays in referral to tissue viability specialists
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to maintain pressure-relieving mattress function
Wider context from the report “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.
” Is this part of a recurring concern? Yes — Inadequate management of pressure ulcers .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide regular mobilisation assistance
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Delays in providing nutritional supplementation
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to provide and continue treatment for oral thrush
Wider context from the report “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.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and obtain clinical-governance approval for a rapid-escalation Standard Operating Procedure for high-risk or complex patients.
Verbatim wording from the response “We recognise the need for a rapid escalation process that enables us to recognise every high risk/complex patients who may be resistant to care, which would have triggered a ‘best interests’ meeting and/or multidisciplinary meetings in real time to address the issues staff were experiencing in trying to deliver care. All of this should have been shared and discussed with her Next of Kin so they were aware and understood the extent of this and also the impact/risk(s) it posed. The Trust has developed a Standard Operating Procedure (SOP), currently being approved through our clinical governance process that will systematise the approach for teams who are caring for patients to whom this SOP applies.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold bimonthly Quality Summits for Ward Matrons to reinforce communication with families and staff.
Verbatim wording from the response “By applying this approach to the care delivered to Mrs Divall the Trust acknowledge and accept the concerns of the Coroner. We are aware we need to review and improve our communication with next of kin and, as above, between teams on discharge such as the District Nurses and ward to ensure important information is cascaded avoiding confusion and distress to families. We now have bimonthly Quality Summits which all the Ward Matrons will be attending in person to emphasise the importance of communication between families but also between staff in order to ensure that care provided is of the highest quality. We have also developed quality documentation audits and discharge checklist audits so that where we see a miscommunication we can put it right in the moment.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind ward staff to offer suitable nourishing drinks before dietitian review and promote high-calorie, high-protein ward options.
Verbatim wording from the response “Following the completion of the MUST or mouthcare assessment on admission, the dietitians will have base line information to work from to enable a full assessment of the patient. Any concerns are highlighted to dietitians via the referral process and from communication with the MDT, patient and family. As part of the learning implemented following Mrs Divall’s experience, all ward staff have received escalated communications to remind them that they can offer nourishing drinks such as Complan shakes and thickened yoghurts prior to dietitian referral or review, as long as there are no concerns about swallowing difficulties/dysphagia. The Dietetic team additionally promote the availability of high calorie, high protein options on the wards to staff and patients.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic prescribing and medicines administration to reduce missed medicines.
Verbatim wording from the response “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular senior nurse-led audits of compliance with MUST treatment plans.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement the 5P discharge process for communicating significant pressure damage.
Verbatim wording from the response “The Chief Nurse has proposed a new process called the ‘5P Process for Discharge’ to improve the communication related to significant pressure damage on discharge. This has been presented and discussed at length with senior nurses across the organisation and is currently being developed and implemented. The process includes utilising our medical illustration team to take clear images of wounds for sharing with carers with consent as required. We have included a copy of the process as Attachment A, and a copy of the 5P slide deck at Attachment B.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the completed Trust-wide inpatient-bed audit to determine effective next steps for mattress protection.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Saturday physiotherapy assessments for new fractured-neck-of-femur patients.
Verbatim wording from the response “When Mrs Divall was an in-patient, we did not have a routine Physiotherapy weekend service and had experienced staff sickness as well. We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
Verbatim wording from the response “By applying this approach to the care delivered to Mrs Divall the Trust acknowledge and accept the concerns of the Coroner. We are aware we need to review and improve our communication with next of kin and, as above, between teams on discharge such as the District Nurses and ward to ensure important information is cascaded avoiding confusion and distress to families. We now have bimonthly Quality Summits which all the Ward Matrons will be attending in person to emphasise the importance of communication between families but also between staff in order to ensure that care provided is of the highest quality. We have also developed quality documentation audits and discharge checklist audits so that where we see a miscommunication we can put it right in the moment.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the impact of electronic prescribing and medicines administration on missed medication.
Verbatim wording from the response “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a Trust-wide audit of MUST assessment quality and treatment evidence.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise, publish and embed the patient-choice treatment-planning policy in relevant training.
Verbatim wording from the response “We have revised the Planning Care Together Policy Respecting Patient Choice with Advised Treatment policy, which provides staff with guidance to manage discussions with patients when agreeing an appropriate treatment, and/or intervention. It encourages family, carers, and advocates to be involved in planning care. This is especially relevant if and when patients are unable to fully cooperate and/or are very resistant to receiving care, where there are concerns about capacity or impaired cognitive function. This policy is on the Trust extranet for all staff to access and it is referred to in training for mental health capacity and has been introduced to the Mouthcare training sessions with immediate effect.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and use a pressure-ulcer After Action Review template under the Patient Safety Incident Response Framework.
Verbatim wording from the response “Under the NHS England’s Patient Safety Incident Response Framework (PSIRF) the Trust have developed a Pressure Ulcer After Action Review (AAR) template in collaboration with the TVN's and the Pure Ulcer Review Group (PURG) – see Attachment F. The aim of PSIRF is to apply a broader approach to addressing patient safety issues, such as pressure ulcers, taking the focus away from investigating individual incidents to instead focus on” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Dietetic Assistant competencies and provide training and support on accurate referral coding.
Verbatim wording from the response “Turning to the prescription of Fortisip, this is typically undertaken following a registered dietitian’s assessment. We accept that doctors could have prescribed this prior to review by a dietitian in this case. On this occasion due to a coding error at the point of triage, the urgency of our response is not as it should have been. Dietetic Assistant (DA) competencies have now been updated and additional training and support are given to DAs regarding the importance of coding correctly at this point in the pathway, to minimise the potential for recurrence of this error.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase physical therapy capacity by employing two full-time Physical Therapist Assistants.
Verbatim wording from the response “We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated Mouth Care Matters Lead role and deliver targeted mouthcare training.
Verbatim wording from the response “The Trust has now established a role (the ‘Mouth Care Matters’ Lead) that is dedicated to the promotion of good standards of mouthcare for patients and targeted training is delivered as per requirements and individual patient need (for example, in the event of a patient who is distressed or failing to comply, additional support and training would be available to staff providing care).” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Verbatim wording from the response “To address these information concerns, we have developed a flow chart on how to refer to District Nurses and what information needs to be shared to support decision making and tasks related to fast track discharge, available on the extranet and in the discharge policy.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete daily hybrid-mattress-pump checks in pilot wards and address identified equipment issues.
Verbatim wording from the response “Additionally, as part of the QI project noted above, Benson Ward and Egerton Trauma Unit now complete daily checks on all hybrid mattress pumps and this is documented on a checklist (Attachment C). Actions are taken to supply pumps to those patients that need them (as all mattresses are hybrid) and address any issues with teams on the ward, who are” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain electronic MUST and mouthcare assessments to record and monitor patient care.
Verbatim wording from the response “We recognise that the mouthcare received by Mrs Divall was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a pressure-ulcer prevention and management quality-improvement project with Tissue Viability Team support.
Verbatim wording from the response “In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential skin damage likely to deteriorate. This is especially relevant to patients who have a history of trauma which often incorporates frailty, poor health and a long lie prior to their admission to the ward. The success of the interventions on this QI project to reduce pressure ulcers in the unit will be reviewed and recommendations extended across the organisation in all wards.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the hybrid-mattress-pump pilot areas across the Trust.
Verbatim wording from the response “supported by ‘trouble-shooting’ sheets (see attachment D). It is our intention to take learnings from these pilot areas and share across the Trust.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide risk-based scheduled mouthcare reviews with electronic prompts and escalation of missed reviews.
Verbatim wording from the response “High risk patients now receive daily mouthcare reviews, medium risk patients are reviewed every other day, and low risk patients are reviewed every third day ensuring that any oral concerns are picked up in a timely manner and managed until improvement is seen. All reviews are prompted on the electronic system and highlighted if not actioned.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A failed hybrid mattress pump would ordinarily still provide sufficient protection against pressure damage, although it did not do so in this case.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RCA was specifically scoped to pressure ulcers, so it did not address other care concerns that were not identified during admission.
Verbatim wording from the response “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.” Source location Response from East Sussex Healthcare
Open published response
Pin
Get email alerts
Request correction
Information checked against the published report and official responses