Floyd, Leah Elizabeth
Deceased
Leah Elizabeth Floyd
Demographics
48y, female
Date of death
2013-10-10
Finding date
2016-12-08
Cause of death
Sepsis due to pulmonary and cutaneous infections, with urinary tract infection and tetraplegia as contributing factors
AI-generated summary
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress deflation, poor repositioning documentation), delayed catheter replacement (5 days without IDC), failure to escalate wound deterioration, and loss of trust in providers due to inappropriate involuntary psychiatric admission and attempted restrictive practices. The patient refused hospital admission due to fear of not being allowed to return home, delaying critical treatment. Clinicians should recognise tetraplegic patients' extreme vulnerability to pressure injuries, ensure robust communication between nursing services and care providers regarding care recommendations, respect patient capacity even with complex needs, and escalate deteriorating wounds urgently.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Prolonged air mattress deflation during critical 24-27 September period
- Delayed catheter replacement (5 days without IDC from 29 September to 2 October)
- Poor documentation of repositioning and pressure relief measures
- Lack of communication of Allied Health nursing recommendations to care staff
- Failure to escalate deteriorating pressure wound from stage 2 to stage 4 (24-27 September)
- Patient refusal of hospital admission due to loss of trust in providers
- Inappropriate involuntary psychiatric admission on 5 September without patient consultation
- Attempted imposition of restrictive practices violating patient rights
- GP failure to examine wound and take swabs on 1 October
- Inadequate discharge planning from second hospital admission (Blue Care not invited to conference, no discharge summary provided)
- Tetraplegia limiting ability to reposition due to neck and shoulder pain
- Smoking and poor nutrition reducing skin integrity
- MRSA colonisation and pseudomonas infection
Coroner's recommendations
- Organisations providing community nursing services should implement clear policies and practices ensuring appropriate communication of care recommendations in community settings with disability service providers employing medically untrained carers
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