In August 2012 Mr R was admitted to a high care nursing home facility, where he required assistance with all daily living tasks and was unable to mobilise independently. 31 days after his admission he was noted to have pressure sores on his heels. In November 2012, further pressure sores were observed on his hip. On 6 February 2013, the wounds were noted to be necrotic.

On 15 February 2013, it was recorded that Mr R had lost 5.7kg in a week. On 16 February, he was hypotensive and had a temperature of 38.7 degrees.

On 22 February 2013, Mr R’s wounds were reviewed by a general practitioner as part of a routine review and it was recommended that he be transferred to hospital. 

However, transfer to hospital did not occur until 23 February 2013, due to difficulty in contacting Mr R’s next of kin. Mr R died in hospital 4 days later from septic shock, due to infected decubitus ulcers complicated by osteomyelitis.

At the request of the coroner, the case was reviewed by a forensic medical officer and a nurse practitioner specialising in complex wound management.

Numerous concerns were raised with the care provided including:

  1. The current policies of the Nursing Home were of a generic nature and did not adequately guide staff as to what action to take when a wound or pressure ulcer occurs or deteriorates. Critically, the following areas were not covered in the policies:
    • Incident management;
    • When to undertake risk assessment and skin assessment;
    • The type of documentation required to be kept by the facility;
    • The reporting process when pressure injuries occur or deteriorate.
  2. An initial risk assessment of Mr R was completed by the Nursing Home on 14 December 2012, some 112 days after he had been admitted. A ‘skin assessment - pressure ulcer risk form’ was not completed until 19 January 2013. Clinical Practice Guidelines recommend that risk assessments should be conducted as soon as possible following a patient’s admission and are to be repeated whenever there is a change in the patient’s condition;
  3. The documentation maintained by the Nursing Home did not meet the minimum standards as required by the Aged Care Standards and Accreditation Agency;
  4. There was no documentation in the records to suggest that the Nursing Home had arranged any referrals to a dietician in response to Mr R’s lack of appetite and recorded weight loss;
  5. An Advanced Care Plan was not in place for Mr R, leading to delay in transferring Mr R to hospital due to the need to contact his next of kin.

Overall, the coroner found that a lack of adherence to evidence based guidelines and regular risk assessment and prevention plans, led to poor treatment and management of Mr R’s bed sores. The paucity of patient records held by the Nursing Home was also of significant concern and would have undoubtedly made effective management of his condition very difficult.

In view of the criticism’s raised, the coroner referred the case to the OACQC for consideration of adequacy of the care provided to Mr R. The OACQC then worked with the Nursing Home to address the shortcomings which had been identified. As a result, a number of significant changes were implemented:

  • Transition to a fully electronic records system
  • A Clinical Team Leader (RN) was appointed with responsibility for the management of clinical issues and management and assessment of wound care, staff education and assessment;
  • A new pressure area audit tool to review an individual’s risk of pressure ulcers, what wounds are present, what pressure relieving equipment and aids are used, what re-positioning, moving and handling requirements are, etc;
  • Additional education being provided to staff internally with regards to wound care/management, nutrition and the importance of maintaining proper and detailed records;
  • The transfer policy for residents to Hospital was updated to stipulate that a resident must be transferred to hospital for assessment/review under the following conditions… sudden or unexplained deterioration of condition… if the RN is unable to contact next of kin, they should still send the resident to hospital unless written instructions are on file stating that the resident does not want to be sent to hospital for medical intervention.

Take Home message

Significant consequences can arise for facilities when issues such as those in this matter are identified. Such consequences may range from reputation damage, accreditation review, to formal complaints being lodged by residents or their families.

Facilities should ensure that systems are in place for regular reviews of policies and procedures to be undertaken and that such policies and procedures are in line with evidence based practice. It is also important that all staff are familiar with the documentation requirements for the facility and that such documentation accords with the minimum standards as required by the Aged Care Standards and Accreditation Agency.

To read the Coroner's Findings, click here.