“Evidence was given by medical staff from the District Nursing Team of the Central and…”

The coroner’s concerns

Evidence was given by medical staff from the District Nursing Team of the Central and North West London NHS Foundation Trust: 1. Staff from the District Nursing Team (Nurses, HCAs, Tissue Viability Nurses and Nursing Assistants) attended on Mr Pearce at his home address fairly regularly between 21.7.2019 and the 15.9.2018. 2. On many of those visits photographs and measurements of his left knee wound were taken; 3. The condition of that wound severely worsened during this 2 month period to such an extent that tendons and bone were visible yet he was never urgently referred to hospital until carers (who provided a separate care service to the Trust) contacted the emergency services on the 15th September, 2018. 4. The Post Mortem examination of Mr Pearce revealed (inter alia) that the left knee included (a) a wound which measured 12 x 7.5cm exposing the patella, and (b) ulceration exposing the tendon measuring up to 7cm. 5. Despite the clear and obvious worsening condition of his left knee, the deceased was last seen by a Tissue Viability Nurse on the 24 th August, 2018. The left knee would was seen by a nurse who attended on Mr Pearce on the 20th August, 2018 who described it as “really bad”. 3 I am concerned that: (a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted. It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed; (b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals; (c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself; (d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.

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, 2019-0068

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