Lesley Marie Krommendijk · Prevention of Future Deaths report

On 30 June 2025 an investigation commenced into the death of Lesley Marie Krommendijk, age 79. The investigation concluded at the end of the inquest on 7 November 2025. The conclusion reached at the inquest was as follows: Died as a consequence of complications arising from injuries sustained from unwitnessed falls at her home.

The medical cause of death was:
1a) Sepsis
1b) Pneumonia
II) Peri-prosthetic right hip fracture, osteoporosis, peripheral vascular disease

On on 31st May Mrs Krommendijk had a fall at home where she slipped over her blanket. Mrs Krommendijk was taken to Stepping Hill Hospital where it was confirmed that she had fractured her right hip. The consultant stated that an injury of this nature would typically be managed conservatively (non-surgically) with weight-bearing as tolerated. Mrs Krommendijk was discharged home on 5th June.

The team that discharged Mrs Krommendijk reported that she was mobile and fit for discharge. Mrs Krommendijk’s son stated he has never seen his mother as mobile as was described by the hospital or the subsequent teams who cared for his mum at home. Mrs Krommendijk’s son explained how he would frequently, with the assistance of his partner and his mum’s neighbours, assist his mother up from the bed to the commode, following her discharge home on 5 June 2025, as she was unable to do this alone. This differed from the account provided by those that provided care to Mrs Krommendijk. I preferred the evidence of the family and am concerned that the discharge was too early and therefore potentially unsafe.

The entries by the Discharge to Assess Team and those by the Intermediate Care Team and Physiotherapists do refer to the pain and difficulty which Mrs Krommendijk’s experienced when trying to mobilise whilst at home. The Reach team who took over the support calls from 12 June 2025 have made no mention or reference to any mobility issues or pain which Mrs Krommendijk experienced from 12 to 16 June 2025.

On 18th June, the Reach reablement team, who were visiting Mrs Krommendijk during a scheduled call, arrived at Mrs Krommendijk’s house to find her lying on the floor.

On 19th June Mrs Krommendijk’s was admitted by ambulance to Stepping Hill Hospital as she appeared confused. Mrs Krommendijk’s son had arrived at Mrs Krommendijk’s home. When Mrs Krommendijk’s arrived at hospital she had a chest x-ray which revealed patchy consolidation in her right lung field, blood tests showed a raised CRP and low sodium.

Sadly, Mrs Krommendijk died on 20 June 2025 at Stepping Hill Hospital.

(1) The current processes for assessing whether or not it is safe to discharge a patient appear to have led to an unrealistic impression of the patient’s mobility.