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Wendy Afford

2024-0478
Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

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Robert Simpson

Berkshire

30 August 2024

Report recipients

Domiciliary care provider

Care home staff kept poor quality records of Wendy's condition. As a result her skin condition was not being managed properly, and she died as a result of pressur ulcers. The electronic care management system was not being used effectively, and the care home managers weren't able to monitor risks.

Issues raised
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