Norma Lockton · Prevention of Future Deaths report

On the 5thMarch 2020 , I commenced an investigation into the death of Norma Lockton, aged ninety years. The investigation concluded at the end of the inquest on the 18th December 2020.

The conclusion of the inquest was a Narrative Conclusion as follows:

Norma Lockton was a resident at Jubilee Court Nursing Home. She was a vulnerable frail woman of 90 years, subject to a Deprivation of Liberty Safeguard Order at the time of her death.
Norma was found in early February 2020 to have vulnerable skin pressure areas, and increasing contractures of her knees, with reduced mobility. She was seen by a district nurse on the 8th and 9th February 2020, and a clear regime set out, written down, and given to care staff, to prevent pressure damage to Norma’s skin. These instructions were not followed and Norma developed a deep wound behind her left knee, because the bandage and pressure relieving pad were not changed regularly, nor washed regularly, and the area of skin under the bandage was not checked regularly.
Norma developed cellulitis of her leg as a result of this wound becoming infected on 29.2.20. The cellulitis was not recognised to have developed as a result of the wound, nor was it recognised as a serious and life threatening condition. No medical assistance was called for Norma until she had advanced cellulitis, and systemic sepsis, by which time, antibiotic and fluid treatment was ineffective.
Norma died in Bassetlaw Hospital, Worksop, Nottinghamshire on the 4th March 2020.
Norma would on a balance of probability have survived, had the skin care instructions given by the District nursing team been followed.
Her death was contributed to by Neglect.

Norma, whilst having some health issues, was in reasonable physical health for her age until late February 2020. She had become less mobile with increasing stiffness and pain in her legs in early February. She was dependant on care staff for all her personal care and mobility needs.
She was at increased risk of skin damage as her mobility reduced, and she was seen by the District nurse team. They organised a plan to protect her vulnerable skin areas, and this was not followed by the care staff.

A wound developed behind her left knee that was not noticed by care staff. It led to cellulitis and systemic sepsis and her death.
The cellulitis was not recognised as a serious condition for two to three days, and therefore no medical assistance was sought.
There was also no regular repositioning of Norma.

1. The lack of an updated skin integrity care plan, with little understanding by the management as to why there had been no update to it following the clear District Nurse instructions regarding skin care.
2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred.
3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans
4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening.
5. The lack of robust review by the management team following a death.