Maureen Edna Dick · Prevention of Future Deaths report

On 26th January 2022 I commenced an investigation into the death of Maureen Edna Dick. The investigation concluded at the end of the inquest on 27th February 2023. The conclusion of the inquest was a narrative conclusion:

Mrs Dick died as a result of a hospital acquired pressure ulcer. Her death was contributed to by neglect.

Mrs Dick was admitted to Queens Hospital on the 4 September 2021. She was very unwell on admission to hospital with likely sepsis from a respiratory source. She had recovered from the respiratory point of view by mid-September 2021. On admission to hospital, she was at very high risk of developing a pressure ulcer, yet she did not receive early, careful risk assessment and care planning to prevent the development of a pressure ulcer. Mrs Dick was not re-positioned in accordance with hospital policy and a pressure ulcer developed shortly after her admission to hospital. The sacral pressure ulcer slowly deteriorated over the course of the admission to Queens hospital. By the 24 October 2021 the pressure ulcer had deteriorated to a Grade 3. By the 24 October 2021 the pressure ulcer is likely to have been infected but no medical attention was given to it. There was no wound swab or liaison with microbiology; a lumbar MRI scan was not carried out and no antibiotics were administered. Mrs Dick was transferred to Broomfield Hospital from Queens Hospital with a likely Grade 4 pressure ulcer and osteomyelitis. She received a very good standard of care at Broomfield Hospital, but sadly optimal treatment at this time could not address the severity of her condition. She died on the 8 January 2022 at Broomfield Hospital from her infected hospital acquired pressure ulcer.

1. There was a lack of professional curiosity by the medical staff in relation to investigating the cause of Mrs Dick’s severe pain in October 2021.
2. There was a failure by the medical staff to adequately assess the sacral pressure ulcer between the 24th October to 29th October 2021, particularly in light of the increasing white cell count and severe pain complained of by Mrs Dick.
3. There was a failure to diagnose Osteomyelitis at Queens Hospital prior to her transfer to Broomfield Hospital on the 29th October 2021.
4. There is no system for mandatory training for clinical staff in relation to pressure ulcers.