Coronial
QLDhospital

Non-inquest findings into the death of Mr W

Deceased

Mr W

Demographics

82y, male

Date of death

2022-01-20

Finding date

2024-11-20

Cause of death

sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis

AI-generated summary

An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was not placed on a pressure-relieving mattress on admission and was left to self-manage positional changes despite poor mobility and declining cognition. The pressure injury developed around 17 December but appropriate wound care documentation and escalation to medical staff were delayed. After transfer to a transitional care facility, the injury progressed from stage 2 to stage 4 within two weeks, complicated by equipment malfunction and documentation gaps. He developed sepsis and necrotising fasciitis requiring palliation. Clinical lessons include: immediate implementation of pressure-relief strategies for high-risk patients, proper documentation and photography of wounds, timely medical escalation, adequate handover between facilities, and equipment maintenance checks.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • delayed placement on pressure-relieving mattress despite high-risk assessment
  • inadequate pressure area care documentation and monitoring
  • patient left to self-manage positional changes despite poor mobility and cognitive decline
  • incomplete and inconsistent clinical documentation
  • inadequate handover of pressure injury information between facilities
  • delayed wound care assessment and management
  • malfunctioning pressure-relieving mattress not promptly replaced
  • lack of escalation to medical staff regarding pressure injury development
  • incomplete transfer documentation and discharge summary
  • gaps in inter-professional communication between nursing, allied health, and medical teams

Coroner's recommendations

  1. Ensure documentation meets minimum required standards through targeted training and annual audits
  2. Implement formal referral process to senior nurse clinicians with wound care qualifications
  3. Establish clear expectations regarding patient rounding and bedside clinical handover
  4. Review and improve transfer documentation processes
  5. Develop and implement standardised pressure injury risk assessment and prevention tools to avoid conflicting advice
  6. Ensure all pressure-relieving interventions are acknowledged and actioned by the nurse caring for the patient, not delegated to patient self-management
  7. Escalate development or worsening of pressure injuries to the admitting doctor
  8. Implement wound photography with metric scale measurements and patient consent documentation
  9. Conduct weekly wound reassessment as per medical practitioner direction
  10. Establish multidisciplinary champions for wound care within facilities
  11. Develop and implement malfunctioning equipment flowcharts with clear reporting and follow-up processes
  12. Provide inservice education on pressure relieving support surfaces and risk assessment documentation
  13. Implement comprehensive intake checklist for referrals to ensure current and complete clinical information transfer
  14. Establish escalation of care procedures for recognising and responding to acute deterioration with graded assertiveness training
  15. Transition medical governance from GP-led model to geriatrician-led model with senior medical officer support
  16. Implement afterhours nurse practitioner model and extend team leader coverage
  17. Conduct regular audits of all pressure relieving equipment functionality and replacement
Full text

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