“The inquest heard evidence that when he was discharged to the care home from the acute…”

The coroner’s concerns

– The inquest heard evidence that when he was discharged to the care home  from the acute hospital that the care home felt that they did not understand  what was required regarding wound care because the care plan regarding  wound care was not clear .The Trust did not have a copy of what information  had been provided. As a consequence of this, there was a lack of clarity  regarding wound management.   The Trust did not the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation  to care plans that included wound management.   The home did not have a clear escalation policy for actions to be taken when a  resident arrived, and their staff were unclear how they were being asked to  manage a wound by the hospital. In addition, the documentation surrounding  concerns and attempts to escalate was limited.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0564

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0