John Willis Humphries · Prevention of Future Deaths report

On 30 March 2020 an investigation was commenced into the death of John Willis Humphries. The investigation concluded at the end of the inquest on 5 August 2021. The conclusion of the inquest was:

“Mr Humphries died from fluid on the lungs and a lung infection caused by a range of conditions including an infection caused by catheterisation in the context of diminishing reserves to which pressure sores contributed.”

Mr John Willis Humphries was admitted to Croydon University Hospital on 7 January 2020 from a nursing home with a two-day history of abdominal pain. Whilst in the Emergency Department, he developed the start of pressure sores. He was admitted to Fairfield 1 Ward the following day. He was assessed as being at risk of pressure sores and the plan included repositioning at 2-hourly intervals. Mr Humphries was on occasion resistant to turns. The staff did not seek advice from external professionals or from the nursing home as to how to manage that behaviour. As a result, the pressure sores deteriorated significantly during his stay in hospital. The pressure sores contributed to his lowering reserves. Whilst in hospital, he was catheterised to monitor his urine output though a decision was taken by a doctor for him to be catheterised permanently as this was thought to be a more humane way of dealing with his incontinence and immobility than incontinence pads. Mr Humphries was discharged back to the nursing home on 15 January 2020 but deteriorated and was readmitted to hospital on 15 February 2020. He developed recurrent urinary tract infections in hospital caused by his catheterisation. His diminishing reserves made him increasingly unable to respond to antibiotics and he died 11 March 2020 from pulmonary oedema and pneumonia caused by the infections and other underlying health conditions.

(1) I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E.
(2) When Mr Humphries resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted.