An inquest took place into the death of Christiana Pelle, who died on 29 September 2016, aged 83.
Mrs Pelle was a patient in Homerton University Hospital from 18 May – 22 July 2016, having experienced a fall. The discharge plan envisaged her returning to live at home supported by a care package. She had an earlier diagnosis of late onset schizophrenia.
Whilst living at home Mrs Pelle developed a grade 4 pressure ulcer on her sacrum which in turn caused a serious infection that spread to her bones. She was admitted to Homerton University Hospital with this condition on 9 September 2016. The pressure ulcer that became infected was first noted on 10 August 2016. It then developed during a period when she was under the care of the Community District Nursing team and in receipt of a care package that was planned to involve four visits a day by two carers.
The inquest found that Mrs Pelle died, having contracted pneumonia during the period from 9 September 2016 when she was receiving inpatient treatment for an infected pressure ulcer. The medical cause of death was found to be: 1a bronchial pneumonia; 1b sepsis; 1c sacral and calcaneal pressure ulcers.
At the conclusion of the inquest the Assistant Coroner expressed the view that there is a risk that future deaths will occur unless action is taken. As a consequence, the Assistant Coroner reported to the Medical Director at Homerton Hospital.
The Assistant Coroner recorded his matters of concern. He stated there was a lack of clear guidance and thus on-gong uncertainty on the part of the nurses at Homerton’s Community District Nursing Team, as to when they should seek involvement of a community patient’s GP.
Another area of concern was the absence of any/ any clearly understood system or procedure for sharing relevant information to a community patient and/or escalating concerns about the quality of the care they were receiving, between Hometon’s Community District Nursing Team and other partner agencies involved.
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