Man died at Hereford hospital after ‘unacceptable’ failings

Herefordshire’s Wye Valley NHS Trust has apologised for the care given to George Griffiths after a Prevention of Future Deaths report was submitted by the coroner.

Mr Griffiths died after a stay in the hospital in early 2022, having been admitted by ambulance on February 1 that year with an acute kidney injury, gastritis, poorly controlled diabetes, and infected toes.

He developed a “significant” pressure sore during his stay, which doctors believed had contributed towards his death.

Herefordshire coroner Mark Bricknell said in his report, sent to the trust after the June 14 inquest recorded a narrative conclusion, that Mr Griffiths appeared to have been held in Hereford County Hospital’s emergency department for more than 40 hours, during which his footwear was not removed. He had a necrotic toe, and there was no evidence of appropriate management or referral.


The trust said the NHS was experiencing unprecedented demand at the time, and excessive waits were a symptom of this, but admitted that it was unacceptable that Mr Griffiths had been left in a position where his footwear was not removed and the pressure damage to his toe identified and managed in a timely manner.

A review has taken place and policy has been updated, the trust said.

Mr Bricknell’s report also said that while Mr Griffiths’ admission paperwork showed his skin was intact on admission, there was no evidence of preventative pressure care during his 40-hour stay in the emergency department and fie-day stay in the acute medical unit. Acknowledgement of pressure area damage occurred on February 8, but no reassessment took place until February 20, with a consequent failure to implement pressure relieving measures.

The trust said a serious incident investigation clearly outlined their failure to assess and treat Mr Griffiths’ pressure damage appropriately, but said the trust was “experiencing significant staffing shortages”, and that this had “undoubtedly played a part in our failure to appropriately assess, escalate and plan his care”.

It said that improvements are being made to the trust’s digital patient assessment and care plan systems, regular audits on the quality of completion of care plans and assessments are undertaken and monitored, and the process for requesting pressure care equipment has been modified.

The Prevention of Future Deaths report also said that the pressure sore Mr Griffiths acquired in the hospital had contributed to his death and noted that pressure area care training is not mandatory within the trust.

But, the trust said, while care training is not mandatory, front-line nurses and nursing associates do receive pressure area prevention, assessment, and care planning education, while a local competency package has been developed and piloted and will be rolled out more widely once evaluated.

Wye Valley NHS Trust said it was very sorry for the inadequate level of care that Mr Griffiths had received and that it would continue to make changes to improve practice.

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