Floyd, Leah Elizabeth

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

1. 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