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  • Prevention of Future Deaths report – Jane Bruce (29 October 2021)

    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Catherine Mason
    • 29/10/21
    • Everyone

    Summary

    Jane Bruce was discharged from hospital on 24 March 2020 and was receiving wound care from the community nursing team twice a week, after surgery on a fracture following a fall in November 2019. She initially appeared to be recovering until 29 April when her pain increased significantly, rendering her bed-bound, with the exudate from the wound significantly increased. She continued to deteriorate and presented to Leicester Royal Infirmary on 1 May with features consistent with sepsis, and subsequently died the following day.

    In her report, the Coroner highlights concerns about an absence of continuity in Ms Bruce’s wound care. She notes that she had been seen by several different nurses but due to lack of photographic evidence/accessible electronic records they did not have the relevant information to recognise the change in her condition.

    Content

    In her report, the Coroner states her main concerns as follows:

    • Ms Bruce was cared for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for reference and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not, meaning Ms Bruce’s change in condition was not fully appreciated.
    • Leicestershire Partnership Trust has learned from this and District Nurses now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record a patient's blood pressure, oxygen saturation levels and temperature.
    • Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere.

    This report was sent to the Department of Health and Social Care, Leicestershire Partnership NHS Trust and University Hospital of Leicester NHS Trust.

    Prevention of Future Deaths report – Jane Bruce (29 October 2021) https://www.judiciary.uk/publications/jane-bruce-prevention-of-future-deaths-report/
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