On 25th February 2015 commenced an investigation into the death of Norman Arthur BEARD aged 87 years. The investigation concluded at the end of the inquest on 27th September 2016 The conclusion of the inquest was that Mr Beard died from infected pressure sores to which neglect contributed. The cause of death was given as: 1a. Sepsis. 1b. Infected pressure sore_ IL Urinary tract infection

The deceased suffered a fall at his home address on gth October 2014. He was admitted to the University Hospital North Staffordshire and transferred to Leek Moorlands hospital on 11th October 2014 for rehabilitation: He developed small moister lesions on bottom which were referred to tissue viability nurses and treated. He was eating and drinking well and his weight was stable. He transferred to Daisy Bank Nursing Home Cheadle on 22nd November 2014. The home's management team were often absent and communication between management and staff proved difficult: Financial difficulties resulted in staff, equipment, food and other essential supply shortages. Clear protocols and polices were not in place: The deceased developed serious pressure sores. No contact was made with tissue viability nurses until 15th December 2014. Advice to upgrade his mattress was not followed: There was confusion with regards to further referrals to the tissue viability nurses and a second referral was not made until Sth January 2015. Records were not fully maintained and there were gaps in turning charts. The deceased was sometimes noted to be non-compliant with his medication and care regime He Iost over 3 stone in weight during his week stay: There was no referral t0 district nurses, dietician or mental health services. The involvement of the general practitioner was minimal. Blood tests revealed a raised erythrocyte sedimentation rate indicating possible infection but no treatment was prescribed and there was no further investigation: Tissue viability nurses attended on him on 7th January 2015. He was found to be in He had infected pressure sores, contracted limbs and significant weight loss. He was readmitted to Leek Moorland Hospital on 8th January 2015 and found to have extensive multiple pressure sores and dehydration: He was transferred to Abbey Court Nursing Home, Buxton Road; Leek 0n 3rd February 2015 and died there on 14th February 2015 Coroncr'$ Chambcrs, 547 Hartshill Road, Stokc-on-Trent; ST4 6HF Tcl 01782 234777 Fax 01782 232074 his pain.

In my opinion action should be taken to prevent future deaths and believe you or your organisation has the power to take such action.