Jeanette Ann Robinson · Prevention of Future Deaths report

On 5/1/17, an inquest was opened into the death of Jeanette Ann Robinson who died on 21/12/16 at Royal Cornwall Hospital Turo. At post-mortem, the cause of death was identified as:
1A) systemic sepsis (coagulase-negative staphylococcus and mixed anaerobic organisms)
1B) infected sacral decubitus ulcer (operated)
1C) morbid obesity and diabetes mellitus (type II)
II frailty
On 24/5/19, I concluded an inquest into the death of Mrs Robinson and recorded a narrative conclusion namely, that she died as the result of an accident. An unsuccessful attempted transfer into a community hospital contributed to the outcome.

I found that Mrs Robinson was a lady with a number of health issues that included morbid obesity and type II diabetes mellitus. She suffered a fall on or about 30/10/16 which reduced her already limited mobility. There was a delay in referring her to the district nurse team. Mrs Robinson developed a sacral pressure ulcer in early December 2016. A special mattress designed to relieve pressure to vulnerable areas was found to be accidentally deflated on 12/12/16. This caused a significant worsening in the condition of the wound. An attempt was made to admit Mrs Robinson into St Austell community hospital on 16/12/16 but this failed due to the wrong form of conveyance being organised. Mrs Robinson was admitted, in a septic condition, into Treliske hospital on 19/12/16. Despite further treatment, she deteriorated and died in the hospital on 21/12/16.

Mrs Robinson was using a nimbus 3 air mattress and a Toto (electronic turning device) at the time the mattress was found to be accidentally deflated. The mattress became deflated when the power cable into the pump was dislodged. I understand there was no alarm fitted to the system or any other warning to alert Mrs Robinson to the developing problem.
I understand that you are the director with responsibility for the equipment loan service in Cornwall.
I do not know whether this was an isolated incident or part of a bigger concern but given the significant contribution the failure of the device had in terms of its contribution to Mrs Robinson’s death, I felt it appropriate to bring the incident to your attention.