Maureen POWELL · Prevention of Future Deaths report

On 17 October 2024 I commenced an investigation into the death of Maureen POWELL aged 95. The investigation concluded at the end of the inquest on 10 June 2025. The conclusion of the inquest was that:

Maureen Powell died from severe frailty, a natural disease. The pressure ulcer she experienced contributed to the medical cause of death.

After a long and active life, Maureen Powell suffered a series of health problems in the months leading up to her death, resulting in a very long stay in hospital. She had suffered a stroke and a fractured neck of femur, as well as other medical problems, and was unable to fully recover. She moved from hospital into a nursing home.

Maureen Powell’s death was from severe frailty but this was contributed to by a large and serious pressure ulcer. That ulcer developed and worsened whilst Maureen Powell was in a nursing home during the period following her discharge from hospital.

It was the policy of that nursing home to provide a high standard of care for residents at risk of pressure damage as well as those who had suffered pressure damage. Suitable equipment and caring regimes were available to provide this support to reduce the risks of the damage worsening or to heal damage which had occurred. Many aspects of the care which was indicated for the pressure damage were not implemented. This more than minimally contributed to the development of the sacral pressure ulcer which, in turn, contributed to the death.

1. Repositioning was undertaken, but recording and implementation was, at times, patchy;
2. There was widespread non-compliance with the regime of daily skin inspections in the period of time that Maureen was a resident at the Nursing Home. Not one skin inspection was recorded during Maureen’s stay;
3. Care plans were not updated regularly in line with good practice and were not always updated when the circumstances required;
4. There was a delay in putting an appropriate bed surface in place;
5. On at least one occasion the airflow mattress was incorrectly adjusted, reducing its efficacy;
6. The family were not kept up to date about deterioration in the wound;
7. The referral to tissue viability was made too late as it occurred after the wound had got beyond the ability of the in-house nursing staff to manage and treat the wound;
8. No internal investigation was undertaken;
9. Key records were not kept or were lost or destroyed;
10. Inaccurate reports were made to the CQC and social care about the incidents; and
11. There was an apparent lack of clear guidance to staff as to what to do if or when pressure damage was identified.