An elderly woman died after she was left in the same position for 14 hours , where she developed horrific bed sores.
Phyllis Tromans, 80, was a long term resident at a residential home in Birmingham but was moved to Queen Elizabeth Hospital in central Birmingham to be treated for pneumonia. On her she was rated as high risk of developing painful sores and was supposed to be repositioned every four hours to avoid them.
An inquest heard the pensioner, who had Parkinson's disease and was said to be in a 'frail condition', spent almost 18 hours in the department. During that time she was positioned on a trolley 'without pressure area care'.
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Vanessa McKinlay, assistant coroner for Birmingham and Solihull, was told on 22 occasions, the schedule was “not adhered to” and she developed a pressure ulcer, also known as bed sores, after being in the same position for 14 hours.
Mrs Tromans died on May 24 at the care home. An inquest heard there were significant 'gaps' in the 'frail' pensioners care.
Ms McKinlay has now issued a prevention of future deaths report into Mrs Tromans passing, after raising multiple 'concerns' surrounding her treatment. The assistant coroner said: “On a total of 22 occasions the schedule was not adhered to.
“This led to occasions where Mrs Tromans was left in the same position for up to 14 hours. The Matron's investigation into these gaps in care did not seek to establish why they had occurred.
"This raises a concern about the quality and efficacy of the Trust's post-death investigations which in turn raises a concern for future deaths. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken."
Ms McKinlay sent the report to University Birmingham Foundation Trust who have until December 27 to reply.
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