Investigation and inquest
On 29/09/2014 I commenced an investigation into the death of Dorothy Imsson, aged 82. The investigation concluded at the end of the inquest on 05/04/2016. The conclusion of the inquest was:
Dorothy Imsson died on 9 August 2014 at Cleveleys Nursing Home from a naturally occurring stroke caused by atrial fibrillation. Dorothy Imsson's death was contributed to by an absence of pressure care planning by qualified staff resulting in a premature development of severe skin ulceration, a shortening of life and increased pain and suffering.
Circumstances of the death
The circumstances of the death are fully set out in the attached Summing Up and Conclusion.
Coroner’s concerns
(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.