Agenda item

6.1  Ying Butt, Deputy Chief Nurse, Community, Guy's & St Thomas' NHS Foundation Trust (GST) ;Cliff Bean, Director of Patient Safety, SlaM ;  Tamsin Hooton, Director of Service Redesign , SCCG and Professor John Moxham, Director of Clinical Strategy, King’s College Hospital presented and contributed to this item .

6.2  Ying Butt, Deputy Chief Nurse (GST)  presented Guy's & St Thomas report on Community Acquired pressure sores and noted that in the time period inquired about there were 19 pressure ulcers acquired prior to visiting hospital and three of the patients were Southwark residents. Ying Butt explained that when a pressure ulcer is identified as not acquired while receiving care from Guy’s and St Thomas’ services it is still reported to the commissioners and if there are any safeguarding concerns a referral to the local authority safeguarding team will be made in accordance with pan London safeguarding procedures.

6.3  A member asked about procedures and the Tamsin Hooton , SCCG , explained that there is a requirement for services to make a record of all pressure sores for people receiving health services, including funded nursing care. A member asked if there was guidance on this and he was told there was. Health professionals explained that there was a recent meeting on developing better protocols for sharing information about pressures sores between providers and commissioners . Cliff Bean, SlaM, commented that they are now monitoring this better as there is a focus on pressure sores through the Patient Safety Thermometer.

6.4  Members asked if there has been an increase in pressures sore and clinicians said that hospitals are seeing an increase of stage 2 and 3,  and sometimes grade 4, pressure ulcers in patients not seen previously by clinicians. Professor Moxham  commented that King’s is seeing an increasing number of frail elderly people  coming in to hospitals needing total care and also intensive care. The Deputy Chief Nurse, GST,  explained many patients have co morbidity .Cliff Bean, SlaM, commented this often involves people with dementia or on an end of life path.

6.5  A member asked if pressures sore were caused by carers not turning mattress or not enough nurses. Professor Moxham said there had never been more care, and mattress, and more resources focused on this in hospitals. Members asked for the causes and clinicians explained that extra cases may be from private residents and from private care homes and they will be looking at this forensically.  Cliff Bean, SLaM, explained that people can acquire a serious  pressure sore very rapidly, for  example in one case somebody collapsed and could not move; by the time they were found they had developed a pressure sore. There were concerns raised that care in the community is not working.

RESOLVED

The Trusts will provide:

Follow up information on how community acquired Pressure Sore cases are resolved, with particular focus on quarter 2 2012/13 and new protocols being developed.

An analysis of why Pressure Sores are increasing, including data on where these are acquired.