Cecilia EDWARDS · Prevention of Future Deaths report

On 4 November 2020, I commenced an investigation into the death of Cecilia Edwards, aged 91 years. The investigation concluded at the end of the inquest on 18 February 2021. I made a determination of death by natural causes.

The medical cause of death was:
1a Citrobacter koseri pneumonia and infected pressure sore of
the right elbow complicating with osteomyelitis
1b immobility and malnutrition
1c end stage dementia
2 general frailty

Cecilia Edwards was admitted to the Whittington Hospital on Saturday, 26 September 2020 generally unwell, with a severe right elbow infection. She deteriorated and died in hospital two weeks later.

District nursing care was provided by Whittington Health.

1. On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse.

However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-ordinator until 22 September 2020.

2. 60% of the district nurses who visited Cecilia Edwards were agency nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to address.

That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation. Ultimately this would improve patient care.

3. The district nurses who visited Cecilia Edwards needed the assistance of the two carers to turn her and attend to all her nursing needs, but sometimes when they visited there were no carers present and so the nursing care given was incomplete.

The carers attended at set hours four times a day, and so it seems that the onus was on the nursing team to arrange the twice weekly visits appropriately.

Sometimes, individual nurses would ring individual carers to make arrangements, but there was no organisational system to ensure that nurse and carer visits coincided as a matter of routine.