Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0119, written 4 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2024 |
|---|---|
| Reference | 2024-0119 |
| Deceased | Stanley Cummins |
| Coroner | Janine Richards |
| Coroner area | County Durham and Darlington |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | County Durham and Darlington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of County Durham and Darlington NHS Foundation Trust CORONER I am Janine Richards, assistant coroner, for the coroner area of Durham and Darlington. CORONER’S LEGAL POWERS I 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. INVESTIGATION and INQUEST On the 16th of September 2022 an investigation into the death of Stanley Cummins, aged 84, was commenced . The investigation concluded at the end of the inquest on 1st of March 2024. The conclusion of the inquest was a narrative conclusion as follows:- Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis. The pressure ulcer was caused as a result of the deceased sitting for long periods of time in a chair and pushing his heel onto the floor in an attempt to reposition, as he was in discomfort from damage which he had also sustained to his bottom. The pressure damage occurred in his care home between the 18th of July and the 2nd of August 2022, where he had been admitted for rehabilitation. The ulcer was an avoidable injury with appropriate care and management of the known high risk of pressure damage. Despite pressure damage being noted to the deceased including to his buttocks and legs there were no comprehensive changes to his care regime, to reduce the risks of further damage occurring, or to manage the pressure damage that had already been caused, becoming worse. There was no referral to the District Nursing team or other professionals for further advice in relation to pressure damage. If the skin had been appropriately monitored it is likely that the early effects of pressure damage to the heel would have also been identified, at which point pressure relief and offloading should have been provided. Once the deceased returned home and the pressure damage to the left heel was identified, no offloading advice or recommendations were given to family and carers from the nursing team responsible for his care, and it is likely that despite the deceased's other risk factors for pressure damage and for delayed healing of such, that with appropriate advice and care, namely complete offloading, amongst other measures, that further deterioration and evolution of the wound, would have been avoided. The deceased died of sepsis, the underlying cause of this was the pressure sore to the left heel which developed into a necrotic ulcer. The wound was preventable with appropriate care and further deterioration of the wound was also preventable. The death was contributed to by neglect. 4 5 6 7 8 CIRCUMSTANCES OF THE DEATH Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022 where he had been discharged on a palliative basis. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds. I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals. The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29.04.24. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons - the family of Stanley Cummins, and to the care home in which he resided for a time. I am 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. 9 04.04.2024 SIGNED BY CORONER
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Executive Corridor
Darlington Memorial Hospital
Hollyhurst Road
Darlington,
DL3 6HX
18th April 2024
Mrs. Janine Richards,
Assistant HM Coroner,
County Durham
Dear Mrs. Richards,
Re: Mr. Stanley Cummins
We are writing in response to your request for the Trust to take action in relation to the lack of
comprehensive evidence provided to you at inquest that lessons had been learnt in relation to
the accepted failings in the care of Mr Cummins, and in particular:
-
-
the failure by the District Nursing team to provide appropriate offloading advice and
recommendations to family and carer’s in accordance with NICE guidelines, once
pressure damage to the heel had been identified, or
to escalate these issues as needed to other services and professionals to prevent
future deaths,
which you issued to County Durham & Darlington NHS Foundation Trust following Mr.
Cummins inquest held on March 1st, 2024.
The Trust would like to offer, its sincere condolences to Mr. Cummins’ family for their loss. We
take very seriously the concerns which you have raised and have provided a detailed response
below along with an action plan with clear timeframes (Appendix A).
An action has been taken to ensure that nurses complete a visit and reassessment for patients
admitted to care homes for intermediate care within 72 hours of their admission. This is part
of the Urgent Community Response (UCR) criteria. This will facilitate the District Nurses to
be involved in MDT care around nursing needs as a high majority of these beds in hours are
commissioned in residential care and therefore this patient group may not have identified
nursing needs before admission to a care home. All intermediate care patients will now be
admitted through Community Crisis process requiring an assessment by a nurse before
admission, and a new care plan will be launched when a patient is admitted to a care home
for a nurse review within 72 hours. This will identify any input or recommendations.
The wound assessments and care plans in SystmOne are being reviewed and updated to
include photography and advice re: off-loading and onward referrals.
Study days have been booked for key staff in all community nursing teams for June 27th and
28th 2024. This will include the launch of the updated assessments and care plans, equipment
updates, incident reporting updates and the use of heel off-loading.
The new wound assessments have been coded to facilitate audit. The audit will be completed
twice a year, commencing November 2024 (allowing time for the new process time to be
embedded) and will include a number of specific wound types for example heel pressure
ulcers and appropriateness of plans of care.
Work has commenced with both equipment suppliers and Podiatry to source a choice of heel
off-loading devices as currently there is only the option of one choice of heel off-loading device.
Patient/carer information leaflets are also being developed regarding off-loading.
We trust that the measures already implemented and those planned are sufficient to address
the concerns you have highlighted. However, please feel free to contact us if you need any
additional information or have further queries.
Yours sincerely
Executive Director of Nursing
Executive Medical Director
cc.
, CEO
, Associate Director of Nursing, Patient Safety and CNIO
See every Prevention of Future Deaths report matching County Durham and Darlington NHS Foundation Trust, 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.