Susan Elizabeth CLISSOLD · Prevention of Future Deaths report

On 12 June 2024, I commenced an investigation into the death of Susan Elizabeth CLISSOLD, aged 72. The investigation concluded at the end of the inquest on 23 June 2025.

The medical cause of death was:
1a) Sepsis Secondary to Infected Burn and Pressure Sore
1b) Multiple Sclerosis
1c)
2)

The conclusion of the inquest was:
Natural causes

Mrs Clissold had multiple sclerosis and was registered blind. She had carers four times per day. Mrs Clissold had a pressure sore on her sacrum which district nurses came in to dress. On 29 April 2024, Mrs Clissold scalded her leg with hot coffee and suffered a burn. This too required regular dressing. On 15 May 2024, Mrs Clissold was admitted to Norfolk and Norwich University Hospital with a temperature and low blood pressure and symptoms of infection. She was treated with IV antibiotics and fluids. Mrs Clissold's condition at times improved but then deteriorated. On the morning of 31 May 2024, Mrs Clissold's condition deteriorated and shortly thereafter a referral was made for palliative care. Mrs Clissold died on 9 June 2024.

1. District nurses were required to attend to Mrs Clissold on a weekly basis. On several occasions they did not attend because they did not have sufficient members of the team available.
2. Evidence was heard that individual cases are becoming more complex involving greater input from the community nursing team and there are an increasing number of patients requiring support.
3. Norfolk Community Health and Care NHS Trust has taken steps to try to ensure there are sufficient staff to attend to patients in the community as required, such as by relocating staff on a temporary basis and prioritising patients.
4. However, evidence was heard they are not able to attend to every appointment as required