Donna Levy · Prevention of Future Deaths report

On 15th December 2022, this Court commenced an investigation into the death of Donna Levy aged 51 years. The investigation concluded at the end of the inquest on 22nd August 2023. The conclusion of the inquest was a narrative conclusion;

“Donna Rose Lydia Levy died in hospital on 14th December 2022 due to complications of a pressure sore she developed in the community. The pressure sore developed due to self-neglect despite support from community health organisations.”

Ms Levy’s medical cause of death was determined as;

1a Sepsis secondary to pressure sore
1b Frailty secondary to self-neglect

Donna Levy was housebound. She was admitted to hospital by ambulance as she had become critically unwell. On admission she was observed to present with signs of severe self-neglect.

Ms Levy was found to be suffering from a significant number of skin lesions on her chest, armpits, anterior lower legs and the entirety of her posterior lower limbs reaching as far as her sacrum. Ms Levy had moisture lesions on her buttocks and thighs along with an ungradable pressure sore which had become infected.

Ms Levy had severely oedematous lower limbs, the skin on her legs and feet had extensive calluses which had caused chronic ulceration, discoloration and a tree-bark texture. Her toenails were long, infected and discoloured.

The deceased had extensive uterine fibroids that had progressed to the stage that they impeded her mobility and continence.

Ms Levy had clinical signs of sepsis and a stage two acute kidney injury.

The patient was admitted to hospital by ambulance and underwent surgical debridement of dead ulcerated skin and tissue, following surgery she succumbed to infection despite maximal medical support and died on 14th December 2022.

1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided. Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions.

2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect.

3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.

4. No formal Mental Capacity Act assessment was ever undertaken or considered.

5. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care.

6. The Trust responsible for community care did not undertake a Serious Investigation. The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time.