Three sores found on Reg Roff when he was admitted to hospital were grade four, the worst level.
An inquest at Bedford into his death was told the wounds had reached deep into his skin and on to ligaments.
Coroner David Morris ruled the ex-car worker died after "less than optimal treatment for the sores" at Carrington House Care Home in Leighton Buzzard.
He was admitted to the care home after suffering a stroke at home in Linslade in June 2008.
After treatment in the stroke unit at the Luton and Dunstable Hospital, Mr Roff was unable to return home and was placed at Carrington House on 17 July.
On 13 November he was readmitted to the stroke unit, where he died on 23 November.
Procedures changed
Specialist Sylvia Leonard told the inquest that when she examined the widower his sores were "the worst I had seen for a very long time in their nature and severity".
Mrs Leonard told the coroner if pressure sores are identified quickly enough their effects can be reversed.
The primary care trust carried out an investigation into the way Mr Roff was treated at Carrington House and this was presented to the inquest.
The author Caroline Brant found staff had not attended training on the use of pressure-relieving equipment.
Health care assistants were also asked to perform wound care with "no evidence of competency", the inquest was told.
Staff who attended wound care training had not put it into practice and treatment was not assessed and was unsupervised, the report said.
An action plan is being drawn up, the hearing was told.
No comments:
Post a Comment