DAPHNE MCCORKLE · Prevention of Future Deaths report

DAPHNE MCCORKLE, then aged 93 years, died on 20 November 2014. An investigation into her death was opened on 28 November 2014 and an inquest held over 19 April 2016 and 8 September 2016.

The medical cause of Mrs McCorkle’s death was recorded as follows:

I(a) Sepsis
I.(b) Infected pressure sore
II. Pancreatitis and right sided cerebral infarction

I returned a narrative conclusion as follows:

Mrs McCorkle was discharged from hospital on 2 October 2014 with a Grade 2 pressure sore. This deteriorated while she was being treated in the community and on 4 November 2014 she was admitted to hospital (University Hospital, Lewisham). She died there on 20 November 2014 as a consequence of sepsis caused by the pressure sore, which had become infected.

The circumstances of the death are as follows:

(1) Mrs McCorkle was discharged from hospital on 2 October 2014 with a Grade 2 pressure sore.

(2) On discharge from hospital a care plan required that she be visited by District Nurses while she was in the community.

(3) I accepted expert evidence to the effect that there were a range of issues with the care Mrs McCorkle received from the District Nurses (which had to some degree been accepted by the Trust).

(4) These issues included concerns about (i) the number of visits that were made to see Mrs McCorkle; (ii) the quality of the assessments at those visits; and (iii) the quality of the documentation (which meant one could not be confident that the proper assessments were carried out or plans put in place).

(5) Further, (iv) there had been inadequate reviews of the care plans that were made; and (v) by the time Mrs McCorkle’s pressure sore became a grade 3 pressure sore (on 18.10.14) the Tissue Viability Nurse should have been contacted, but this did not occur until very late in the chronology (on 31.10.14).

(6) Finally there was evidence before me that (vi) the District Nurses had not provided the professional carers or members of Mrs McCorkle’s family with advice that they should have received to ensure regular turning of her at night.

(7) I accepted the expert evidence that in many cases if they are properly treated, pressure sores can be reversed in terms of their classification and that if proper, or the best, treatment is given, pressure sores can be avoided entirely

(8) However Mrs McCorkle’s pressure sore did deteriorate and she became very unwell in late October 2014. On 4 November 2014 Mrs McCorkle was admitted to hospital (University Hospital, Lewisham). She died at University Hospital, Lewisham on 20 November 2014 as a consequence of sepsis caused by the pressure sore, which had become infected.

(9) I concluded that on the balance of probabilities, the issues with Mrs McCorkle’s care by the District Nurses, as identified above, more than minimally contributed to her death.

(1) On the expert evidence, there will be cases where a patient should be turned every 2/3 hours, even at night, to ensure that the risk of pressure sores being caused or worsened is properly managed.

(2) In some cases where this level of turning is required, family members will not be able to perform that task.

(3) However I was informed during the inquest that Lewisham District Nurses (for whom I understand the NHS Lewisham Clinical Commissioning Group is responsible) will not visit patients at home at night.

(4) I was also informed that agency carers (whose care I understand is commissioned by the London Borough of Lewisham, Adult Social Care Department) will not visit at night either.

(5) This leaves a gap in provision for some patients and is a concern.