Leonard Hudson
PFD Report
Historic (No Identified Response)
Ref: 2014-0419
Coroner's Concerns (AI summary)
Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
View full coroner's concerns
Civic Centre; Burdon Road; Sunderland, SRZ 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland www sunderland gov-ukicoroner Henry aged May
, as follows During the course of Mr Hudson in-patient admission from the of 2013 to the 13th of August 2013, did not follow the requirements of the Trust Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted Due to the co-morbidities of Mr Hudson, he ought to have been identified as having & higher risk factor_ Mr Hudson ought to have been referred to the foot protection team in a more timely manner The nursing documentation was not a5 comprehensive as it ought to have been_ The classification of Mr Hudson's heel injuries was "variable" From the evidence given by the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson: would like to draw them to your attention, as follows:
1) there were episodes of inadequate record keeping; for example;, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson's dialysis; although physiotherapists attended the ward on two occasions per Mr Hudson was absent from the ward for three dialysis and there was no contingency provision physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect; I did not make that 2 |V 4 13th May staff that; day being day, days having for they finding:
However; some aspects of Mr Hudson $ care could impact on the care of others and you will appreciate my to draw these matters to your attention Iknow that some of them have already been addressed, particularly in respect of the matters received in evidence by but I shall be glad of your response to this Report To Prevent Future Deaths.
, as follows During the course of Mr Hudson in-patient admission from the of 2013 to the 13th of August 2013, did not follow the requirements of the Trust Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted Due to the co-morbidities of Mr Hudson, he ought to have been identified as having & higher risk factor_ Mr Hudson ought to have been referred to the foot protection team in a more timely manner The nursing documentation was not a5 comprehensive as it ought to have been_ The classification of Mr Hudson's heel injuries was "variable" From the evidence given by the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson: would like to draw them to your attention, as follows:
1) there were episodes of inadequate record keeping; for example;, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson's dialysis; although physiotherapists attended the ward on two occasions per Mr Hudson was absent from the ward for three dialysis and there was no contingency provision physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect; I did not make that 2 |V 4 13th May staff that; day being day, days having for they finding:
However; some aspects of Mr Hudson $ care could impact on the care of others and you will appreciate my to draw these matters to your attention Iknow that some of them have already been addressed, particularly in respect of the matters received in evidence by but I shall be glad of your response to this Report To Prevent Future Deaths.
Sent To
- City Hospitals Sunderland NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
19 Nov 2014
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 26/03/2014 an investigation into the death of Leonard Hudson;, 74 was commenced. The investigation concluded at the end of the inquest on 23th September 2014. The conclusion of the inquest was Accident contributed to by complications arising from diabetes
Circumstances of the Death
Mr Hudson fell at his home address on the 12th 2013 and was admitted to Sunderland Royal Hospital on 13th May 2013 for surgery to repair a fracture of the right neck of femur which appeared to meet it's objectives. Given Mr Hudson's other medical conditions particularly his diabetes he was susceptible to pressure sores the management of which was challenging: On the I6th October 2013 Mr Hudson underwent a below the knee amputation of his right leg: As a consequence of his immobility he developed bronchopneumonia from which he died on the 19th March 2014 at his home address Pelton Fell Chester le Street
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and I believe you have the power t0 take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.