Clifford William ROSE · Prevention of Future Deaths report

On 12 August 2022 I commenced an investigation into the death of Clifford William ROSE aged 80. The investigation concluded at the end of the inquest on 14 October 2022. The conclusion of the inquest was that:

Clifford William Rose died on the 10th August 2022 at Florence Nightingale Hospice, Aylesbury. He had suffered a burn on his leg from an electric blanket that became seriously infected. He had his leg amputated on 4th August 2022. Failures in the assessment of his care needs and to escalate concerns of his deteriorating health and his own self neglect contributed to his death.

Clifford William Rose died on the 10th August 2022 at Florence Nightingale Hospice, Aylesbury. He had suffered a burn on his leg from an electric blanket approximately 6 weeks prior that became seriously infected. He had his leg amputated on 4th August 2022. His cause of death was reported to the Coroner as:
1a) Multi Organ Failure
1b) Myocardial Infarction
2) Ischaemic Heart Disease, Full Thickness Burn to Left Lower Leg

During the course of the evidence at the inquest it became apparent that detailed assessments of the needs of very vulnerable and perhaps elderly patients are being carried out over the telephone. In this particular case, it lead to the deceased confirming that he was able to dress himself and that he was eating and drinking regularly. This was far from the correct position. I believe that consideration should be given to put in place a system whereby all assessments are carried out face-to-face and where appropriate should involve another member of the family.