Beatrice Smith · Prevention of Future Deaths report

On 1 May 2025 I commenced an investigation into the death of Beatrice SMITH. The investigation concluded at the end of the inquest . The conclusion of the inquest was a narrative in the following terms:

Beatrice Smith was 88 years old. On 22nd September 2024 Mrs Smith was admitted to the Cumberland Infirmary, Carlisle, following a fall and long lie. Mrs Smith had a serious ulcer on her left leg. Whilst in hospital there was a period of one month during which Mrs Smith's ulcer was not seen or treated by Tissue Viability Nurses. Following their involvement, Mrs Smith's condition began to improve, but she had developed further ulcers including to her right heel. Mrs Smith was discharged to Riverside Court Care Home on 13th February 2025. Whilst resident there Mrs Smith's condition deteriorated seriously and the ulcer on her right heel became badly infected. Mrs Smith's condition noticeably worsened from 15th April onwards. Despite this, Riverside Court did not seek specialist attention for her and the ulcer was not always properly dressed. Mrs Smith developed sepsis. She was admitted to the West Cumberland Hospital, Whitehaven on 23rd April 2025. She died there at 17:01 on that day.

Neglect, being the failure to seek specialist care and wound management for Mrs Smith following her deterioration on 15th April 2025, contributed to her death.

I concluded that the medical cause of Mrs Smith's death was:

1a Multiple Organ Failure

1b Sepsis

1c Infected Heel Ulcer

II Diabetes Mellitus, Dementia, Frailty

Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on Call on 17th April 2025. They both had significant concerns about Mrs Smith's condition and the ACP made a safeguarding referral. The ACP's note (which she wrote at the time) was as follows:

"sat in chair on arrival. evident leaking haemerous fluid from the right foot/ankle this was leaking underneath her sensor mat with noted blood clots on the floor from the exudate....I was very shocked at how Beatrice was sat with her leg wound pooling out in her room under her sensor mat. Daughter has raised concerns that this was how it was when she arrived yesterday".

The Manager of Riverside Court attended the inquest and gave evidence. I asked her how Mrs Smith had been allowed to develop such a poor condition. She responded that she had attempted to find this out but had not been able to. She confirmed that she would have expected staff to conduct rounds and that they should have addressed Mrs Smith's deteriorating condition. She was not able to tell me why this had not occurred.

I understand that Harbour Healthcare Limited is now the owner of Riverside Court.

(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.

2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.