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Coroner raises patient safety concerns over lack of Bedfordshire tissue viability nurses


A senior coroner has voiced serious concerns about a lack of tissue viability nurses in Bedfordshire, after investigating the death of an elderly woman who died from sepsis caused by infected pressure ulcers.

Thomas Osborne, senior coroner for Bedfordshire and Luton, warned more people could die if action was not taken to address shortages of tissue viability nurses both in the community and at Luton and Dunstable University Hospital.

“We have increased the provision of tissue viability nurses over the past two years”

Trust spokeswoman

He called for an urgent review after investigating the death of 88-year-old Jean McHale, who had been discharged from hospital in April last year with grade 2 pressure ulcers.

According to her daughter, she was seen daily by community nurses and carers. But she went on to be admitted to Luton and Dunstable on 9 July 2016 with what were then two grade 4 pressure ulcers in the sacral region, the coroner’s report revealed.

Ms McHale underwent multiple antibiotic therapy for five weeks. However, her condition failed to improve.

An inquest into her death, conducted by Mr Osborne, concluded she had died from sepsis from infected pressure ulcers.

The inquest had revealed “matters giving rise to concern” he said in his report sent to the chief executives of Luton and Dunstable Hospital University Hospital NHS Foundation Trust and South Essex Partnership University NHS Foundation Trust, which provides community nursing services in Bedfordshire.

“We have a good provision of tissue viability services in place for our patients”

Sheran Oke

The concerns highlighted in the letter included the fact “there are not enough tissue viability nurses working in the community or in the hospital to meet the needs of patients”.

“If pressure ulcers are not treated appropriately then the elderly in the community will suffer, develop osteomyelitis leading to sepsis and death,” warned Mr Osborne.

“During the course of the inquest, the evidence revealed matters giving rise to concern – in that the number of tissue viability nurses both in the hospital and in the community is limited,” said Mr Osborne in his report.

“In my opinion there is a risk that future deaths will occur unless action is taken,” he said in the Regulation 28 report, which coroners have a duty to submit if they feel there is a risk of other deaths occurring in similar circumstances.

Luton and Dunstable Hospital University Hospital NHS Foundation Trust

Exclusive: Coroner warns of tissue viability nurse shortage

Luton and Dunstable Hospital

South Essex Partnership said a review of its tissue viability service had been carried out and the trust would be discussing increasing nurse numbers with local service commissioner Bedfordshire Clinical Commissioning Group (CCG).

“A full review of the tissue viability service has been undertaken and we can confirm that clear pathways are in place to ensure timely and effective referral into the service,” said a spokeswoman.

“We have increased the provision of tissue viability nurses over the past two years and provide training for our community nurses in the prevention and early detection of pressure ulcers,” she said.

“We have informed Bedfordshire CCG, who commissions our tissue viability nurse service of the outcome of the inquest,” she said. “As a result, we are meeting with the CCG to discuss reviewing the commissioned levels of tissue viability nurses in the community.”

Sheran Oke, acting director of nursing and midwifery at Luton and Dunstable, told Nursing Times that the organisation had a robust tissue viability service with a good track record.

“We have a good provision of tissue viability services in place for our patients, which is demonstrated by a sustained reduction in hospital acquired pressure ulcers year-on-year,” she said.

Luton and Dunstable Hospital University Hospital NHS Foundation Trust

Exclusive: Coroner warns of tissue viability nurse shortage

Sheran Oke

“Since 2012 we have embarked on a programme of education, training and investment and we have two full time tissue viability nurses in post, and comprehensive training in place,” said Ms Oke.

She added that the organisation had introduced root cause analysis for every grade 2, 3 or 4 pressure ulcer in order to identify any omissions in care and share learning across the trust.

Tissue viability nurses worked closely with clinical teams and the trust had increased ward-based training and study days, she noted. Staff carried out daily spot checks, with a focus on identifying pressure sore early and managing them appropriately.

“The wards review their data at a monthly quality performance meeting with the director of nursing and midwifery, and performance is overseen through the clinical outcome safety and quality committee, and by the trust board,” said Ms Oke.

“The most recent data demonstrates that we are providing a good service to our patients, maintaining optimum performance on pressure sore prevention,” she told Nursing Times.


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Readers' comments (11)

  • Shortage of Tissue viability nurses this may be true but there is a shortage of nurses overall!

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  • I offer condolences on Mrs McHale's death. I find myself wondering though what other contributing factors were involved in this sad outcome?
    Mrs McHale apparently sustained the sores when in hospital in the first place and not whilst at home. What took her to hospital and how did she respond to the treatment she received there? Did Mrs McHale have a nutritious dietary and fluid intake? Were faecal or urinary continence issues contributing factors? Was Mrs McHale mobile, was she able to turn herself when in bed or sitting in a chair? Did any other morbidities add to the burden on this unfortunate lady's system? Was she on medication that increased the likeliehood of her developing pressure sores?
    Having spent a career caring for the frail elderly my understanding is that, generally speaking, no single factor contributes to pressure wounds. Rather they occur after an acute episode of ill health or a generally deteriorating level of health which leads to the largest of our organs suffering damage. Even specialist Tissue Viability Nurses surely struggle to keep skin intact or to heal breaks when up against circumstances that contribute to such outcomes? How can we address the inevitable aging or dying processes which contribute to pressure damage and skin breaking down? Risk assessments are in place, protocols are followed but alas pressure sores still occur. We need to remember the 'bigger picture' when reading articles like this in my opinion and think around the problem. Will pressure wounds ever become obsolete?
    Tissue Viability Nurses are useful to the NHS - especially with our aging populace (of whom I am one), who are living longer due to good medical and nursing care coupled with a generally better standard of living than our predecessors.
    Nurse training should be aimed at teaching the highest standard of what we used to call 'basic' nursing care. That is the foundation of excellent care.

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  • Less paperwork, more hands on nursing care and we might get fewer pressure sores.

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  • Respect to Thomas Osborne for the Regulation 28 finding, and to the histopathologist and coroner's police whose investigations must have been sufficient to permit this finding unlike some.

    At my mother's inquest there was much spin, omissions and misrepresentation and, to my great regret, no Prevent Future Deaths (PDF) finding and so I am still haunted by the knowledge that others are still likely to be sitting for prolonged periods of time in their own urine and faeces with pressure sores or ulcers that may or may not have been reported in a timely manner to the Care Homes GP Practice. These pressure sores may still be being covered in cloth bandages instead of appropriate dressings. The service users with repeated and hidden pressure sores may yet be given antibiotics repeatedly, purportedly not for pressure sores but for chest infections, even against wishes recorded in an Advance Decision not to have life-prolonging treatment when suffering dementia. These vulnerable people detained by law in Care Homes (by, I allege, inadequately qualified and/or remarkably foolish senior NHS and LA managers and DoLS co-ordinator/manager) may still be suffering day and night, ad infinitum, whilst GPs, psychiatrists and community psychiatric nurses turn a blind eye and ignore their duty to report any suspicions of neglect to the CQC and continue to fraudulently take home pay for attending to the needs of these vulnerable people in the 5th richest nation in the world.

    My respect to this Coroner's Court who have done what they are paid to do and done their bit to prevent a miserably dying process and avoidable harm and humiliation to our vulnerable elderly.

    To Sheran Oke - not good enough!

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  • Ms Oke

    OUTCOMES not chat!

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  • Pressure sores will never cease to exist entirely but that is no reason to accept avoidable ones which likely form the major amount.

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  • 24 February, 2017 10:20 pm : Anonymous
    I agree with what you say with regards to nonsense, spin and the appalling 'deal' or care that befall the frail and the elderly whilst senior 'people' debate policy. It's not good enough.
    You do not need 'Tissue Viability' nurses to prevent pressure sores: they are experts that you can consult with regards to prevention and treatment (and they may have access to funds) but the solution is with the appropriate training of ALL staff who care for skin....this isn't complicated - really it isn't I know because I do it - if you educate carers with knowledge and understanding with regards to the anatomy and physiology of pressure sores then you are giving them the tools with which to care and be vigilant ....but it is about individuals and management taking responsibility and being accountable for their actions and training of their staff.
    I would also say that the management of Sepsis and the prevention and management of pressure damage are usually two different things.

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  • I believe that repeated pressure sores can cause septicaemia which in turn can lead to sepsis but other than that I wholeheartedly agree with what you say and wish that all others in care work were equally well educated.

    However some LAs and CCGs appear to be determined to continue to keep service users who are in residential care and are self-funding in that category. It has been recognised that this is a covert method of using unreasonably high residential fees from self funders to top up the residential fees for those who have assets below the threshold set by LAs and are therefore due to be funded by the Local Authority. This reduces the financial burden on the LA. And if the NHS refuses to assess accurately in a timely manner and pay out in a lawful manner, they do not pick up the bill either.

    It also means that the service user, being a resident not a patient, cannot receive more nursing care than they can get from the visiting District Nurses. This means that should they need more intensive nursing care from the nurses in a nursing home they are not allowed to receive it. Thus health conditions inadequately treated, can deteriorate to the point that pressure sores eventually develop.

    The tissue viability nurse is instrumental in ensuring that the service user is assessed appropriately. It is no guarantee, of course, where the LA and CCG employ poor quality managers and staff and are systemically below lawful standards and abusing their power, that this would automatically happen.

    Likewise where GPs, CPNs and Psychiatrists turn a blind eye to the lack of fluids, activities and pressure relief alongside the inappropriate use of anti depressants with sedative properties (which can add to problems because they reduce movement, ability to take in fluids and can actually cause itchiness) it is no guarantee that lawful requirements will be met. But hopefully more tissue viability nurses might help and perhaps they could be instrumental in educating care home staff, carers and nurses, on the issues that you highlight?

    And maybe those other Coroners, unlike Thomas Osborne, might do more than say things along the lines that staff are doing their best delivering care to people with challenging behaviour. Perhaps the behaviour of those people would be nowhere near as challenging if they were treated with person centred care instead of treating them as sacks of potatoes!

    Perhaps other Coroners would do well to give out more findings of Regulation 28 to prevent future (miserable) deaths.

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  • Anonymous
    24 February, 2017 10:20 pm
    25 February, 2017 3:02 pm
    What are you both talking about?? Care Homes were not involved at any stage, the sores were caused by the Hospital and the treatment was given in the Lady's own home (daily), if a Care Home had been found responsible I am sure there would have been a huge outcry and even litigation .
    One rule for the Public Sector and another for the Private, the staff are there where is Safeguarding in all this ? I know they would be on the front line if this had been in a Private Sector home.

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  • You are sure there would have been a huge outcry? You sure are living in a zone without hard evidence. And litigation is not a feasible option for most people.

    Safeguarding does not work as it should which has recently been highlighted in the news. This means that vulnerable people are in reality unprotected.

    This forum is not obliged to confine itself to hospital or care home. The issue is pressure relief and the outcomes where it is inadequate.

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