JANET MARY TRIPP · Prevention of Future Deaths report

On 15 January 2025 I commenced an investigation into the death of 85 year old Janet Mary Tripp.

The investigation concluded at the end of the inquest on 18 December 2025.

The medical cause of death was found to be as follows:

1a Ischaemic right foot and Frailty of Old Age
1b Peripheral Vascular Disease
2 Non healing pressure Ulcer on Right Heel, Cerebrovascular Disease, Iron deficiency anaemia

The four statutory questions - who, when, where and how – were answered as follows:

Janet Mary TRIPP died on 28 December 2024 at Apartment 10 Ocean 1 Pentre Avenue NEWQUAY CORNWALL from Frailty of Old Age and an Ischaemic right foot caused by Peripheral Vascular Disease. The ischaemic right foot was contributed to by an avoidable pressure sore that developed on Janet’s right heel during a 7 hour stay in the Royal Cornwall Hospital discharge lounge. In that time there was an absence of protective measures that could have prevented that pressure sore. The right heel pressure sore more than minimally contributed to Janet’s death.

The conclusion of the inquest was as follows

Janet died from natural causes contributed to by an avoidable pressure sore.

1. The circumstances are sufficiently explained in the answers to the four statutory questions set out above.
2. The following findings of fact were made in relation to failings in the provision of care whilst Janet was in the Royal Cornwall Hospital discharge lounge awaiting transport to Helston hospital. These failings likely caused the development of a pressure sore that contributed to Janet’s death.

• Lack of care rounds by staff.
• Lack of training regarding basic patient care for some staff working in the discharge lounge.
• Janet was not re-positioned every 2 hours as is required to avoid pressure sores.
• No risk assessment was conducted in the duration of Janet’s stay in the discharge lounge or following the discovery of pressure sores when Janet was still in the discharge lounge.
• No documentation that dressings were required following the discovery of Janet’s pressure sores
• No handover notes to the ambulance service or Helston hospital warning of the development of pressure sores and the need for protective measures.

There was insufficient evidence before the court to indicate that the above failings found at Inquest had been addressed by the hospital.