Dorothy Imisson
PFD Report
Historic (No Identified Response)
Ref: 2016-0496
Coroner's Concerns (AI summary)
The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
View full coroner's concerns
_ (1) No appropriate care plan was developed by the District Nursing Service.
2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping (3) The District Nursing Services are compromising patient care by not following NICE guidelines.
2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping (3) The District Nursing Services are compromising patient care by not following NICE guidelines.
Sent To
- Blackpool Teaching Hospitals NHS Trust
- Care Quality Commission
Response Status
Linked responses
0 of 2
56-Day Deadline
7 Jun 2016
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 29/09/2014 commenced an investigation into the death of Dorothy Imisson, aged The investigation concluded at the end of the inquest on 05/04/2016_ The conclusion of the inquest was: Dorothy Imisson died on 9 August 2014 at Cleveleys Nursing Home from naturally occurring stroke caused by atrial fibrillation: Dorothy Imisson's death was contributed to by an absence of pressure care planning by qualified staff resulting in a premature development of severe skin ulceration, shortening of life and increased pain and suffering:
Circumstances of the Death
The circumstances of the death are set out in the attached Summing Up and Conclusion.
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.