On the August; 2014 an investigation was commenced into the death of Mr: Thomas Jenkins The investigation concluded at the end of the inquest on the 12"h December 2014 medical cause of death was Ia. Sepsis; 1b. Infected chronic pressure sore on right heel; and Ic. Cerebrovascular accident The conclusion of the inquest was a narrative determination Narrative Conclusion: Mr: Thomas Jenkins; 85 years old, died on &h August 2014 on Ward 12 of the Royal Glamorgan Hospital; Wales after developing & pressure ulcer whilst in the care of the Ysbyty Cwm Rhondda Hospital following & cerebral vascular accident Mr, Jenkins was further diagnosed as suffering from cancer and his prognosis was poOr: Treatment of the pressure sore failed, the ulcer worsened, became MRSA infected and was the likely source of sepsis which led to Mr. Jenkins' death.

Mr: Thomas Jenkins suffered a cerebral vascular accident and was admitted to the Royal Glamorgan Hospital on 27.12.13 He was transferred for rehabilitation to Ward C3, Ysbyty Cwm Rhondda on 04,.02,14. He developed a pressure sore on hisright heel which was first noted 0n11.04.14. At about this time he was diagnosed as MRSA positive at his PEG site, eyes and later his pressure sore wound His pressure sore increased in severity from to 2 to a 3/4. He develped a further pressure sore on his right ankle and a left Jlesion Maggot therapy was _ to his right heel and 15"_ The grade grade applied Jeg wound and in this deteriorating condition he was transferred to a nursing home only to be re-admitted to the Royal Glamorgan Hospital within the week. He died 5 days later of sepsis:

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. The consideration would be for increased availability of Tissue Viability Nurse care; implementation of NICE Guidelines and the All Wales Guidance on Essential Elements of Pressure Ulcer Prevention and Management; and training with spot checks to ensure accurate record keeping: