Pauline Stirling · Prevention of Future Deaths report

On 12 March 2024 an investigation was commenced into the death of Pauline Stirling. The investigation concluded at the inquest on 9 October 2025.

The conclusion of the inquest was a Narrative Conclusion:

The Deceased died due to the effects of chronic infection due to pressure damage on a background of natural disease.

The medical cause of death was:
1. Bronchopneumonia, chronic osteomyelitis secondary to pressure sores.
2. Alzheimers Disease, Lewy Body Dementia.

The deceased, who had a medical history which included Alzheimers disease and Lewy Body Dementia, suffered a deterioration in her health in December 2023, which caused immobility, reduced nutritional intake and increased frailty.

She developed multiple areas of pressure damage, from which she was at risk of developing, but which worsened due to lack of clear wound monitoring, wound care plans, and regular 2 hourly positional changes when she became immobile.

A severe pressure wound was incorrectly categorised in a referral for specialist tissue viability nursing input, and other areas of pressure damage had not been assessed, photographed, and documented.

A wound management and care plan was made by the tissue viability nurse comprising daily dressing changes, and 2 hourly positional changes with a 30 degree tilt. This plan was not followed consistently, which contributed to the worsening of the pressure damage and wounds from which healing could not be achieved.

The Deceased continued to deteriorate died at 19.50 on 07/03/24 at Covent House Care Home in Gateshead.

1. To date, the documentation for recording positional changes only requires care staff to input the position right, left, back, in chair with no reference to positional tilt to avoid pressure damage.

2. Whilst evidence was provided about the training requirements for full time members of nursing and care staff, to include mandatory full induction and refresher training, I am concerned having heard evidence that to adhere to the ratio of 2 RGNs per shift, agency nurses were regularly utilised, and no evidence about training requirements was provided.

3. Despite safeguarding referrals made due to concerns about wound management, and the issue of wound care, incorrect classification of pressure damage, and absence of expected documentation being raised initially by tissue viability nurses in January 2024, there is no evidence before the Court of training having been undertaken, including training offered by tissue viability nurses. The only training carried out was online webinar training by a former member of staff in March 2024.

4. There were candid acceptances that documentation was not completed to an accepted standard and there were gaps in the records. This is not the first inquest where acceptances were made, therefore I remain concerned that this is an ongoing issue despite evidence that this has been addressed with an auditing system.