Christiana Pelle · Prevention of Future Deaths report

On 5 October 2016 an investigation was commenced into the death of Christiana Pelle, aged 83 years old. The investigation concluded at the end of the inquest on 28 March 2017. The inquest found that Mrs Pelle died on 29 September 2016 at Homerton University Hospital, having contracted pneumonia during the period from 9 September 2016 when she was receiving inpatient treatment for an infected pressure ulcer. The conclusion of the inquest was a narrative one (see 4, below) and the medical cause of death was found to be: 1a bronchial pneumonia; 1b sepsis; 1c sacral and calcaneal pressure ulcers.

Mrs Pelle was a patient in Homerton University Hospital from 18 May – 22 July 2016, having experienced a fall. The discharge plan envisaged her returning to live at home supported by a care package. She had an earlier diagnosis of late onset schizophrenia. Whilst living at home Mrs Pelle developed a grade 4 pressure ulcer on her sacrum which in turn caused a serious infection that spread to her bones. She was admitted to Homerton University Hospital with this condition on 9 September 2016. The pressure ulcer that became infected was first noted on 10 August 2016 and it then developed during a period when she was under the care of the Community District Nursing team and in receipt of a care package that was planned to involve four visits a day by two carers.

(1) Lack of clear guidance and thus ongoing uncertainty on the part of the nurses in Homerton’s Community District Nursing team as to when they should seek the involvement of a community patient’s GP;

(2) An ongoing absence of any / any clearly understood system for sharing relevant information relating to a community patient and/or escalating concerns about the quality of the care they were receiving, between Homerton’s Community District Nursing Team and other partner agencies involved - in this instance the Community Mental Health Team from the East London NHS Foundation Trust’s City and Hackney Mental Health Care for Older People and the London Borough of Hackney’s Integrated Independence Team;

(3) The lack of a clearly understood system for communicating concerns and/or other relevant information between the Community District Nurses Team and the care provider agency for a community patient.