Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0543, written 19 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2014 |
|---|---|
| Reference | 2014-0543 |
| Deceased | Thomas Jenkins |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend & Glamorgan Valleys |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
T REGULATION 28 REPORT 10 PREVENT FUTURE DEATHS
Re: Mr. Thomas Jenkins, who died on 08.08.14 at the Royal Glamorgan Hospital.
THIS REPORT IS BEING SENT TO:
4. Chief Executive Cwm Taf University Health Board
2. HHJ Mr. Peter Thornton Chief Coroner,
3. EEE Clinical Governance Lead Medicine & Accident and
Emergency, Cwm Taf UHB;
4. EEE, Clinical Governance Lead Medicine & Accident and
Emergency, Cwm Taf UHB;
5. sei ws? Legal & Risk Service; and
6. Son.
4 | CORONER
lam Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys, Bridgend
and Glamorgan Valleys
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 | INVESTIGATION and INQUEST
On the 15" August, 2014 an investigation was commenced into the death of Mr. Thomas
Jenkins.
The investigation concluded at the end of the inquest on the 12" December 2014. The
medical cause of death was 1a. Sepsis; 1b. Infected chronic pressure sore on right heel;
and 1c. Cerebrovascular accident. The conclusion of the inquest was a narrative
determination.
Narrative Conclusion:
Mr. Thomas Jenkins, 85 years old, died on 8" August 2014 on Ward 12 of the Royal
Glamorgan Hospital, Wales after developing a pressure ulcer whilst in the care of the
Ysbyty Cwm Rhondda Hospital following a cerebral vascular accident. Mr. Jenkins was
further diagnosed as suffering from cancer and his prognosis was poor. Treatment of
the pressure sore failed, the ulcer worsened, became MRSA infected and was the likely
source of sepsis which led to Mr. Jenkins’ death.
4 _| CIRCUMSTANCES OF THE DEATH
Mr. Thomas Jenkins suffered a cerebral vascular accident and was admitted to the
Royal Glamorgan Hospital on 27.12.13. He was transferred for rehabilitation to Ward
C3, Ysbyty Cwm Rhondda on 04.02.14. He developed a pressure sore on his right heel
which was first noted 0n11.04.14. At about this time he was diagnosed as MRSA
positive at his PEG site, eyes and later his pressure sore wound. His pressure sore
increased in severity from grade to 2 to a grade 3/4. He developed a further pressure
sore on his right ankle and a left leg lesion. Maggot therapy was applied to his right heel
be re-admitted to the Royal Glamorgan Hospital within the week. He died 5 days later of
wound and in this deteriorating condition he was transferred to a nursing home only to
sepsis.
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7
month period whilst Mr. Jenkins was being nursed in YCR yet response was slow
(as long as a week after a ward visit was requested). In fact the TVN did not assess
the ulcer until 06.06.14 almost 2 months after its development and by which time
the odour from the wound was described as ‘very offensive’. A bandage used was
reported as the likely cause of a new ulcer forming - Datix incident report 14.07.14.
(2
~—
The key concern is that of inadequate TVN and wound care input. The inadequate
care in this instance was attributed to specialist nurses not being based in the
hospital and of insufficient TVNs to serve the several hospitals in the region. The
service being overstretched.
ACTION SHOULD BE TAKEN
{n my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action. The consideration would be for
increased availability of Tissue Viability Nurse care; implementation of NICE Guidelines
and the All Wales Guidance on Essential Elements of Pressure Ulcer Prevention and
Management; and training with spot checks to ensure accurate record keeping.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18" February 2015. |, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Executive, Cwm Taf University Health
Board; Clinical Governance Lead Medicine & Accident and Emergency,
Cwm Taf UHB; Clinical Governance Lead Medicine & Accident and
as Cwm Taf UHB; EEEENV/SSP Legal & Risk Service; and Mr.
son.
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
|
19" December 2014 SIGNED:
Af [fellbvesl Dr. Sarah-Jane Richards
HM Assistant Coroner
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.