Derek Smith
PFD Report
Historic (No Identified Response)
Ref: 2018-0186
Coroner's Concerns (AI summary)
Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
View full coroner's concerns
In the circumstances it is statutory to report to you: It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly Iittle communication with the attending carers as well) . There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith's death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith's treatment. Suitable communication could well be significant factor in other cases. wonder if systems could be changed to ensure better communication between the duty my
District Nursing team, family members and other agencies involved.
District Nursing team, family members and other agencies involved.
Sent To
- Virgin Care Services Limited
Response Status
Linked responses
0 of 1
56-Day Deadline
2 Sep 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29 December 2017 | commenced an investigation into the death of Derek Reginald Smith aged 86 years. The investigation concluded at the end of the inquest on 15 June 2018. The conclusion of the inquest was 'An elderly gentleman with major natural health problems who had developed severe pressure sores'
Circumstances of the Death
Mr Smith lived at home but he could not manage any of his care needs and he was bedbound. He had regular attendances by carers_ He had frequent visits by district nurses and other professionals saw him at times. He died at his home on 21 December 2017 from aspiration pneumonia, On 6th December he had been found to have a pressure sore on his sacrum that went down to the bone_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.