Derek Reginald Smith · Prevention of Future Deaths report

On 29 December 2017 I commenced an investigation into the death of Derek Reginald Smith aged 86 years. The investigation concluded at the end of the inquest on 15 June 2018. The conclusion of the inquest was ‘An elderly gentleman with major natural health problems who had developed severe pressure sores’.

Mr Smith lived at home but he could not manage any of his care needs and he was bedbound. He had regular attendances by carers. He had frequent visits by district nurses and other professionals saw him at times. He died at his home on 21 December 2017 from aspiration pneumonia. On 6th December he had been found to have a pressure sore on his sacrum that went down to the bone.

It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well). There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved.