Background
An 82-year-old gentleman who was a resident in a nursing home since 2015 following a stroke. His wife visited daily, bringing him food to eat and participating in providing care. His nutritional status deteriorated at this time.
In April 2020, the carers raised concern about his skin integrity being compromised. The following day he developed a fever and his GP advised staff to treat the patient as having COVID 19, which was confirmed 20 April 2020.
He developed a grade 2 pressure ulcer on the sacral area. A referral was made to the tissue viability team the same day. The wound was reported as smelly, the resident had a fever on the 2 April and antibiotics were started.
He was admitted to hospital after he was found to be unresponsive on 20 April 2020 and had a Grade 4/unstageable PU with extended area.
Safeguarding concerns
During this period the nation was in the first wave of the global pandemic. Reviews by GPs and MDT members were being undertaken remotely.
The home was overwhelmed with the number of patients and staff becoming infected with COVID symptoms.
A referral to the tissue viability nursing team (TVN) was made early April but there was a significant delay in response from the TVN’s and information provided by the home did not give a complete picture of the situation.
Carers were not skilled in recognition, prevention and management of risks and skin integrity issues.
Key lines of enquiry
- A section 42 enquiry to establish the cause, effect and impact on this gentleman and his family.
- Referral to the SAR board for consideration was made which initiated a wider multi-agency review, incorporating an extended serious Incident (SI) review.
- This was a multi-agency enquiry that explored service issues at a time of crisis to establish areas of concern, good practice and learning across the system.
- The pan London provider concerns process was initiated to seek assurances that the system and learning from this case have been embedded.
Findings
There were significant challenges to provision of consistent care during the pandemic which saw usual resources compromised by the lack of routine contact with the service, demands on the services, staffing levels across the system and usual practices being suspended.
Opportunities in the system were missed to initiate prevention measures such as provision of pressure relieving equipment, nutritional review, early MDT review given the high risk of him developing a pressure ulcer.
The community team services did not offer extended opportunities to access services during this period.
The knowledge of staff on duty in the home about prevention, treating and reporting pressure ulcers was poor which led to inaccurate information being shared with the TVN team and management of the wound being compromised.
Practice implications
- Review and update of skills and systems within the care home
- Due to the extent of the review, lessons have been learned across the system and practice changes have been extended to include all partner agencies.
Implementing change
- Training for care home staff has been completed and systems to review care daily have been implemented.
- Review of lessons learned and practices have been shared in the multi-agency primary care services.