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Investigation and inquest
On 29 July 2022 an investigation was commenced into the death of Karen Lesley Day, aged 58. The investigation concluded at the end of the Inquest on 28 November 2024.
The medical cause of death was
1a) Septicaemia
1b) Soft tissue infection, Pneumonia
1c) Traumatic Laceration
II) Raynaud’s disease.
The conclusion of the Inquest was: Accident.
Circumstances of the death
Karen Lesley Day sustained a small laceration to her left lower leg in 2021 when she injured it on a van. She sought help from her GP practice to manage the wound in June 2021 and appointments with the practice nursing team commenced. Over the course of the following 11 months, Karen attended multiple appointments where the appropriate lower limb framework was not followed and opportunities to escalate Karen’s deteriorating wound and overall condition were missed. Karen was admitted to hospital on the 26ᵗʰ May 2021 and was treated for an acute infection following which she was discharged to the care of the district nursing team. The lower limb framework was not used consistently and opportunities their increasing deterioration was not fully recognised and escalated. She was admitted to hospital on the 12ᵗʰ July 2022 where she was, by this point, extremely unwell. The hospital commenced active treatment to which she did not respond and care was orientated towards palliation and comfort. Karen died on the 14ᵗʰ July 2022.
Coroner’s concerns
(1) During the course of the inquest I heard evidence that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the practice was unable to provide assurance that the same situation could not occur again.
(2) During the inquest I received evidence that the practice had not carried out any internal investigation in relation to this death and the practice accepted it should have done. I am concerned that the practice does not have adequate systems in place to ensure that patient safety incidents are reviewed in a timely way to allow lessons to be drawn from the findings.
Information checked against the published report and official responses