Arthur Cook
PFD Report
Historic (No Identified Response)
Ref: 2015-0300
Coroner's Concerns (AI summary)
Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.
View full coroner's concerns
(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; (2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal.
(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services.
(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services.
Sent To
- Aneurin Bevan University Health Board
- Cwm Taf University Health Board
- National Assembly for Wales
Response Status
Linked responses
0 of 5
56-Day Deadline
21 Sep 2015
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 the 21st April, 2015 I commenced an investigation into the death of Mr. Arthur Cook, 78 years old. The investigation concluded at the end of the inquest on the 3rd
July, 2015. The conclusion of the inquest was ‘Death from a poorly managed MRSA infected wound’.
July, 2015. The conclusion of the inquest was ‘Death from a poorly managed MRSA infected wound’.
Circumstances of the Death
Mr. Arthur Cook suffered from poor circulation and was being treated by vascular surgeons for gout and necrosis of his toes leading to toe amputation. Since March 2014, he had been a patient under the care of both the Aneurin Bevin Hospital Board (ABHB) and the Cwm Taff University Health Board (CTUHB). During this period he had been admitted to the Royal Glamorgan Hospital; the Ysbyty Ystrad Fawr; and the Four Seasons Healthcare Residential Home where he was under the medical supervision of the Bryntirion Surgery, Bargoed, all of which are under the ABHB.
Mr. Cook had further periods of hospitalisation in Prince Charles Hospital which is administered by CTUHB. He was discharged from Ward 31, Ysbyty Ystrad Fawr to the Four Seasons Healthcare Residential Home on 14th
January, 2015 with a chronic open wound to his right knee - an injury sustained when a patient in the Royal Glamorgan Hosptial. Whilst a resident at the Four Seasons Healthcare Residential Home, Mr. Cook developed a wound (possibly pressure ulcer) to the back of the right knee. On the 25th
January 2015 the wound exudate was assessed as ++. At this time tissue viability care was sought from the ABHB and again in February 2015 but the residential home Manager was advised of the lack of availability of specialist nursing advice at that time. TVN advice was not provided until April 2015. At this time Mr. Cook was admitted to Prince Charles Hospital with an MRSA infected category 4 pressure ulcer. He failed to respond to treatment and subsequently passed away.
Mr. Cook had further periods of hospitalisation in Prince Charles Hospital which is administered by CTUHB. He was discharged from Ward 31, Ysbyty Ystrad Fawr to the Four Seasons Healthcare Residential Home on 14th
January, 2015 with a chronic open wound to his right knee - an injury sustained when a patient in the Royal Glamorgan Hosptial. Whilst a resident at the Four Seasons Healthcare Residential Home, Mr. Cook developed a wound (possibly pressure ulcer) to the back of the right knee. On the 25th
January 2015 the wound exudate was assessed as ++. At this time tissue viability care was sought from the ABHB and again in February 2015 but the residential home Manager was advised of the lack of availability of specialist nursing advice at that time. TVN advice was not provided until April 2015. At this time Mr. Cook was admitted to Prince Charles Hospital with an MRSA infected category 4 pressure ulcer. He failed to respond to treatment and subsequently passed away.
Action Should Be Taken
in the area of prevention, diagnosis and treatment of escalating pressure ulcers by:
Ensuring microbiology results which confirm MRSA infectivity are notified to the GP and Community nurses and Residential home staff involved in the treatment of a residential home patient even when results pertain to a patient in a different Health Board’s area;
For the ABHB to ensure staffing levels of tissue viability nurses are such that vulnerable patients (including the elderly who have limited mobility) have access to specialist services to inhibit the escalation of pressure ulcers to the point they are causative of death through infection; and
GPs to be proactive in checking their elderly residential patients are receiving expert nursing input when required.
Ensuring microbiology results which confirm MRSA infectivity are notified to the GP and Community nurses and Residential home staff involved in the treatment of a residential home patient even when results pertain to a patient in a different Health Board’s area;
For the ABHB to ensure staffing levels of tissue viability nurses are such that vulnerable patients (including the elderly who have limited mobility) have access to specialist services to inhibit the escalation of pressure ulcers to the point they are causative of death through infection; and
GPs to be proactive in checking their elderly residential patients are receiving expert nursing input when required.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.