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Investigation and inquest
On 23rd October 2025, I commenced an investigation into the death of Edith Jones born on 22nd May 1932.
The medical cause of her death was determined at inquest to have been:
1)(a) heart failure on a background of an infected Grade 4 sacral pressure ulcer
II Chronic kidney disease, Hypertension, Coronary Artery Atherosclerosis, Frailty
At the end of the inquest, I recorded the following Narrative Conclusion:
Died from natural causes exacerbated by the lack of oversight and management of the pressure ulcer in the community by the District Nursing Team.
Circumstances of the death
Edith May Jones had limited mobility and a number of underlying health conditions including heart failure. She showed signs of sacral moisture damage and the Hyde district nursing team became involved in her care. By 12th August 2025 the wound was showing signs of slight improvement. Visits were reduced to weekly. The clinical rationale was not documented. It should have been. On 16th August 2025 she was visited and the wound had deteriorated. The next visit was scheduled for 21st August. The rationale for the delay until the next visit was not documented. It should have been. On 18th August the family requested an urgent visit due to concerns regarding the sacral wound. The visit did not take place until 19th August. There is no documented rationale for the delay in attending. This should have been documented. On 19th August the District Nurse who attended did not view the sacral wound. They should have. On 20th August the family raised further concerns about the wound and were told a District Nurse would visit on 21st August. On 21st August the dressing was changed. The wound was found to have deteriorated to a large ungradable pressure ulcer since the last time there had been any input on 16th August. On 22nd August and 23rd August the nurses attending did not document their observations of they wound. They should have. By 25th August the wound had deteriorated further. By 26th August she had deteriorated further. On 29th August she was admitted to Tameside General Hospital and treated for an infected stage 4 pressure ulcer. Despite being given intravenous antibiotics for 5 weeks she did not improve and became increasingly frail. She died at the Stamford Unit on 17th October 2025. A post mortem concluded that she had died from heart failure exacerbated by the strain of dealing with the infected grade 4 pressure ulcer.
Coroner’s concerns
1. The quality of the District Nursing team documentation was poor. Consequently, it was difficult to understand the steps taken and the rationale for actions;
2. There was little evidence of oversight by District Nursing Team managers of how complex cases such as Mrs Jones were being managed;
3. There was no prompt escalation of her case by the District Nurses when the situation deteriorated;
4. The District Nursing gateway referral system had a triage process that did not identify or manage proactively her deteriorating condition.
5. The GP practice did not have an effective system to promptly triage referrals from the 111 service or information provided by a patients family.
Information checked against the published report and official responses