Edward John FUNNELL · Prevention of Future Deaths report

On 10 May 2023 I commenced an investigation into the death of Edward John FUNNELL. The investigation concluded at the end of the inquest 10/07/2025. The conclusion of the inquest was Natural Causes.

1a Ischaemic left foot

1b Peripheral Vascular Disease

1c

Congestive Cardiac Failure, Chronic Kidney Disease, Ischaemic Heart Disease, Atrial Fibrilation

These were recorded as :-

Mr Edward John Funnell died on 29ᵗʰ April 2023 at Ystradgynlais Community Hospital. Mr Funnell was admitted to Hereford Hospital on 16ᵗʰ December 2022 for an orthopaedic procedure. During his time at Hereford Hospital he developed a pressure ulcer on his left heel. Mr Funnell was not fit to be discharged home. He was transferred to Llanidloes War Memorial Hospital on 11ᵗʰ January 2023 until admission to Bronlais Hospital and transfer onwards to Morriston Hospital on 19ᵗʰ February 2023. During his time at Llanidloes the pressure ulcer worsened, and he developed an ischaemic left leg. On admission to Morriston Hospital he decided against surgery to amputate his ischaemic left leg and received palliative care at Ystradynlais Hospital from 24ᵗʰ February 2023 until his death. On balance it cannot be said that missed opportunities to treat and escalate the care of the worsening heel ulcer and signs of ischaemia in the left leg contributed to his death.

A finding of natural causes was made. During the course of the inquest extensive evidence was heard in respect of the wound dressings and interventions of nursing and Tissue Viability specialists during the deceased’s time at Bronglais Hospital.

a. There was a lack of appreciation of the need for the deceased to see a podiatrist as recommended by a Tissue Viability Nurse. The referral was not followed up or actioned.
b. There was an identifiable lack of knowledge on the part of the nursing staff to understand the reason for referral to a podiatrist and the possible interventions a podiatrist could undertake in respect of pressure wound damage, particularly in patients with circulatory problems.
c. There was an identifiable lack of knowledge on the importance of following the recommendations of the Tissue Viability Nurse in respect of the type of dressings to be administered and the importance of ensuring such steps were followed as opposed to using an alternative and, on the evidence, an inappropriate dressing.