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Investigation and inquest
On 13 June 2024 I commenced an investigation into the death of Phyllis TROMANS. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Mrs Tromans died as a result of an infected pressure ulcer to her right hip which developed when she was an inpatient in Queen Elizabeth Hospital, to which gaps in her pressure area care during that admission made a contribution.
Circumstances of the death
Mrs Tromans was a long term resident at Cotteridge House Residential Home. She had Parkinson's disease and was in a frail condition. On 17 March 2024 she was admitted to Queen Elizabeth Hospital where she was treated for pneumonia but where her condition did not improve and she was assessed as being for end of life care. Whilst in hospital, she developed a grade 4 pressure ulcer of her right hip, to which gaps in her pressure area care made a contribution. She died at Cotteridge House on 24 May 2024.
Following a post mortem performed by ████████ the medical cause of death was determined to be:
1a Infected Pressure Related Ulcer Right Hip
1b
1c
1d
II Frailty, End stage Parkinsonism with immobility
Coroner’s concerns
1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area care.
2. Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute Medical Unit and subsequently to ward East Ground B. This required repositioning at no greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions the schedule was not adhered to. This led to occasions where Mrs Tromans was left in the same position for up to 14 hours.
3. East Ground B ward had a paper version of a wound care plan which was designed to provide detailed monitoring of her skin condition and a treatment plan for pressure sore care. This was not completed at any stage.
4. The Matron's investigation into these gaps in care did not seek to establish why they had occurred. This raises a concern about the quality and efficacy of the Trust's post-death investigations which in turn raises a concern for future deaths.
Information checked against the published report and official responses