Josie's review in brief

Background

Josie was 76 years old and lived in a residential care home in Stockport before she passed away in February 2023. Josie had previously required support in being independently mobile, and also lived with dementia.

Whilst living in the residential care home, Josie had restricted mobility and because of this she developed moisture lesions which developed into grade 2 pressure ulcers. By December 2022 these had become ungradable. Josie was the subject of a Strategy Meeting in January 2023 which looked at the communication between agencies and the deterioration of her wound.

Josie sadly passed away on 9 February 2023 with her cause of death noted as “vascular dementia, not overtly septic but osteomyelitis from the pressure ulcer on the balance of probability probably contributed more than minimally”.

Stockport Safeguarding Adults Partnership would like to pass on sincere condolences to Josie’s family.

Information sharing and communication

There were some missed opportunities throughout Josie’s care, particularly where she was discharged from District Nursing and moved to a different care home, to handover full care plans. Social Care assessments had identified Josie’s skin as being vulnerable to breaks as she was unable to reposition herself.

Professional visits to care homes should always be clearly documented with care plans and risks shared with all other relevant professionals.

Multi-agency working

Josie was living in a residential care home and was receiving care from District Nurses. In addition, out of hours GPs were also seeing Josie.

The review found it would have been helpful to convene a multi-agency meeting to discuss Josie’s care, and to potentially address any escalating concerns around deterioration of her pressure ulcer.

Safeguarding referrals

Josie was the subject of 3 safeguarding referrals to the local authority between October and December 2022. These resulted in a strategy meeting being called in January 2023.

Safeguarding concerns raised with regards to the deterioration of pressure ulcers can be complex and require clinical knowledge. Local guidance would support professionals to refer and address pressure ulcer safeguarding concerns.

Communication with family

Both of Josie’s sons were consulted by the local authority as part of her care assessments, and at the time of Josie’s admission to the care home, the registered manager met with her sons to discuss the placement. Both sons often visited the care home. However, limited information was shared regarding Josie’s pressure ulcer and the review found there was a lack of clarity around who was responsible for communicating this with family.

Josie was the subject of 3 safeguarding referrals for her pressure ulcer. This process was not fully explained to family members with the implication that a particular agency was to be found to be providing ‘unsafe’ care which was not the case.

Learning points

The review has identified 8 specific learning points which will be addressed through a multi-agency action plan.

  1. There was a missed opportunity between the district nursing teams to handover Josie’s care when Josie was discharged from the district nursing team who covered the locality of the previous care home.

  2. Current policy and procedure with regard to documenting the details of professional visits to the care home in individual’s care plans was not robust.

  3. Perceived differences in status and/or the experience of professionals can affect the confidence of some professionals to pursue concerns.

  4. When an individual’s needs change and concerns are raised with regard to a care home’s ability to provide adequate care, timely coordination of a plan to ensure that the individual is placed somewhere where they can receive the care and support that they need, is crucial.

  5. By not convening a multi-agency meeting to plan Josie’s pressure ulcer management and care, when an agency became concerned for the care she was being provided, professionals missed an opportunity to work within a multi-agency approach.

  6. Safeguarding concerns raised with regard to the deterioration of pressure ulcers can be complex and require clinical knowledge.

  7. Professionals from all agencies must ensure that residents of care homes and (where appropriate) their families are included and kept up to date with care and support planning and are consulted and listened to.

  8. Professionals referring an individual for a safeguarding enquiry should ensure that those subject to the referral and where appropriate, their families are provided with the rationale as to why the process is necessary and what they can expect to happen next.

Next steps

We ask that you:

  1. Circulate and discuss the issues of this briefing within your team.

  2. Review your personal and collective practice in the areas identified.

  3. Attend workshops that the Safeguarding Adults Partnership will be delivering in relation to the learning from this and other reviews.

  4. Download and read the full review:

    Safeguarding Adults Learning Review - Josie

    PDF, 316 KB

    This file may not be suitable for users of assistive technology.

  5. Look at the learning points identified in this review.