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Investigation and inquest
On 27 December 2023 I commenced an investigation into the death of Cynthia Mary Gilbert. The investigation concluded at the end of the inquest on 23 January 2025. The conclusion of the inquest was that Mrs Gilbert died as a result of natural causes contributed to by gaps in the implementation of the pressure ulcer care plan in hospital.
Circumstances of the death
Against a background of cardiac and respiratory illness, Mrs Gilbert’s mobility had deteriorated at home. She was found on the morning of 30 August 2023 on the toilet, where she had been all night having been unable to stand herself up. She was admitted to Musgrove Park Hospital where she was discovered to have an infective exacerbation of her chronic obstructive pulmonary disease and grade 2 tissue injuries to the sacrum and buttocks. During a long hospital admission, Mrs Gilbert’s pressure ulcers deteriorated and became infected, owing in part to her multiple co-morbidities and in part to gaps in the implementation of her repositioning care plan. This caused septicaemia from which Mrs Gilbert died in hospital on 20 December 2023.
The medical cause of death was determined by ████████ (Mrs Gilbert’s treating Consultant Physician) to be:
1a Septicaemia
1b Pressure ulceration
1c Immobility
2 Chronic obstructive pulmonary disease, Congestive cardiac failure, Atrial fibrillation
Coroner’s concerns
a) Mrs Gilbert was noted to have grade 2 tissue damage on admission to hospital. She was assessed as being at very high risk of pressure ulcer development. Her care plan included repositioning every 1 to 2 hours. The Intentional Rounding documents show that, during her time spent on the Old Acute Medical Unit and Coleridge Respiratory Unit (1/9/23 to 20/12/23), Mrs Gilbert remained in the same position in bed for periods of many hours on multiple days.
b) Evidence given by the tissue viability nurse was that the tissue viability team emphasised the importance of repositioning on five separate occasions to the ward staff. The lack of adherence to the repositioning plan continued despite these communications.
c) Mrs Gilbert’s grade 2 tissue damage deteriorated to a grade 4 pressure ulcer during her admission, leading to septicaemia.
d) The lack of adherence to the repositioning care plan for a patient at very high risk of developing pressure ulcers raises a concern for future deaths.
e) The evidence given by the Trust at the inquest did not provide a satisfactory explanation as to why the repositioning care plan was not adhered to. This raises a concern about the quality and efficacy of the Trusts’ post-death investigation which in turn raises a concern for future deaths.
Information checked against the published report and official responses