Ms. Marilyn Anson · Prevention of Future Deaths report

On 9th April 2015 I commenced an investigation into the death of Ms. Marilyn Anson age 60 years. The investigation concluded at the end of the inquest on 3rd February 2016. The conclusion was that the medical cause of death was
I(a) Myocardial infarction; (I(b) Coronary artery thrombosis; II Type 2 diabetes mellitus, hypertension, obesity, cirrhosis and the conclusion as to the death was Natural Causes.

The deceased suffered with type 2 diabetes mellitus and required regular dialysis for end-stage renal failure caused by her diabetes. In 2001 the deceased had undergone a below knee amputation of the right leg. During 2013 she attended regularly the Podiatry Clinic but did not keep appointments during 2014 and on 14th November 2014 she telephoned the clinic and discharged from the service. The GP was advised of this self-discharge by letter of 11th February 2015.

On 13th February 2015 a referral was made by the GP to the North Somerset Community Partnership (NSCP) via their single point of access (SPA) for the community nurses to attend the deceased to examine a skin tear on her leg. For reasons unknown this referral was not acted upon. There is reference in the GP records to a referral being made on 30th January 2015 although it is not known if this referral was actually made at that time.

On 25th February 2015 a further referral was made from the GP practice requesting the community nurses to attend the deceased with regard to the skin lesion on her leg which was now reported to be leaking fluid.

The community nurse from NSCP attended the deceased at home the following day, the 26th February 2015, accompanied by a colleague. On examination the deceased had already dressed the leg wound herself and did not wish to have the dressing removed at that time. However, at the same time she also complained about pain in her left foot which was covered loosely in an absorbent pad. On examination the community nurse discovered the deceased to have a grade 4 pressure ulcer. The area covered by the ulcer was 8cm x 6cm affecting the heel which was black and necrotic but dry. The community nurses dressed the ulcer with an absorbent pad and made an urgent referral was made that same day to the ‘hot foot’ clinic based at Weston General Hospital.

Arrangements were made for the deceased to be seen twice weekly by the community nurse until the appointment at the ‘hot foot’ clinic.

When the deceased was seen on the 2nd March 2015 the community nurse was advised by the deceased that no appointment at the ‘hot foot’ clinic had been received. The nurse telephoned the clinic that same day and was advised the earliest appointment available was 17th March 2015.

On 12th March 2015 the deceased was attended by the tissue viability link nurse from the NSCP who noted high levels of exudate and was malodorous. Visits were increased to three times a week.

By 14th March 2015 the community nurse noted that the ulcer had increased in size. There was also exudate and the wound was still malodorous.

On 16th March 2015 the deceased attended Weston General Hospital for a session of dialysis. She was unwell at the dialysis unit and was admitted to the Emergency Department of Weston General Hospital that same day. She was seen by the tissue viability nurse who noted the whole of the foot to be gangrenous, necrotic and malodorous. The toes were discoloured and there was an excessive amount of macerated, loose skin.

The deceased was transferred that same day to Southmead Hospital, Bristol under the care of the vascular surgeons. She was commenced on antibiotics but it was determined that amputation of the limb was necessary. The initial operation was performed on 19th March 2015. The deceased required further surgery and returned to theatre on 22nd March 2015. Unfortunately following the second operation her condition deteriorated and she died that same day.

(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015.
(2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died.
(3) There should be a review of the means by which patients who are referred to this clinic are prioritised.
(4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients.
(5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively.
(6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need.