Concerns raised about treatment of pensioner at Shrewsbury hospital

Joanna Lees, assistant coroner for Shropshire, Telford & Wrekin, will make a report to prevent future deaths after Peter Sudlow died on April 8, 2019.

The 81-year-old from Shrewsbury developed a pressure ulcer during his month-long stay in Ward 22 between January 23 and February 23.

An inquest heard after he was discharged to Isle Court Nursing Home, the wound became infected which ultimately led to his death.

Mrs Lees said there was missed opportunities to refer Mr Sudlow to a specialist tissue viability nurse (TVN) for expert advice and support.

She said: "What I do find is that there was missed opportunities to get additional support and advice about how best to manage and give Mr Sudlow the best chance to not develop a pressure ulcer or prevent it from becoming worse.

"At no time during his stay at hospital was advice from a TVN sought and I did not hear any satisfactory explanation as to why."

Changes

She raised further concerns about the way Mr Sudlow was transferred to the nursing home on February 23.

"The communication from the hospital to the nursing home was inadequate which placed the home in a difficult position," she added.

"I find that the deterioration occurred in the nursing home to the point it was unsalvageable but I am satisfied that the management was acceptable.

"It had gone past a certain point and it was inevitable that it was not going to heal despite the best effort of the nursing home. Nothing else could have been done."

After the wound became infected and necrotic, Mr Sudlow was taken back to Royal Shrewsbury Hospital and was eventually discharged to Severn Hospice where he died.

Mrs Lees recorded a narrative conclusion that Mr Sudlow died from a naturally incurring infection which originated during a hospital stay.

Following the two-day inquest, Matron Corrin Dorset was called to advise on what changes have been made to the way pressure wounds are managed in Ward 22.

New guidance has been put in place but Mrs Lees said she was not completely satisfied because there is still a gap in the guidance for patients like Mr Sudlow who present with additional needs like paraplegia.