Mr RO'H - Non-inquest findings

Contributing factors

• delayed pressure injury risk assessment and prevention planning
• inadequate wound documentation and management
• failure to recognise correlation between malnutrition and pressure ulcer formation
• failure to refer to dietician despite significant weight loss
• failure to escalate deteriorating clinical signs to general practitioner
• delayed transfer to hospital (6-day delay after clinical deterioration on 16 February)
• further 24-hour delay in hospital transfer pending next-of-kin contact
• lack of adherence to evidence-based guidelines (AWMA 2012)
• inadequate nursing home policies and procedures for pressure injury management
• paucity of patient records and documentation

Coroner's recommendations

1. Nursing home policies must be updated to include guidance on incident management, timing of risk assessment and skin assessment, required documentation types, and reporting processes when pressure injuries occur or deteriorate
2. Staff education is required on wound healing, pressure injuries, and the importance of accurate documentation
3. Implementation of a comprehensive pressure injury prevention and management system, including initial risk assessment upon admission and regular re-assessment
4. Referral to dietician when residents have identified weight loss and nutritional difficulties
5. Recognition and escalation of deteriorating clinical signs, including fever, hypotension, and tachypnoea, to the general practitioner
6. Clear transfer policy stipulating that residents with sudden or unexplained deterioration must be transferred to hospital for assessment, with immediate notification of GP and next-of-kin (and transfer proceeding even if next-of-kin cannot be contacted unless written instructions are on file)