Prevention of Future Deaths report: Elizabeth Roberts (8 January 2024)

Summary

Elizabeth Roberts was severely frail and bedbound, supported by visits from care agency carers four times per day and her local District Nursing Team. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. She was admitted to Tameside General Hospital on 19 May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. In this report the Coroner notes concerns about the her case and the capacity of the District Nursing Team providing here care.

Content

The Coroner stated that concerns about Mrs Roberts care had been raised with Adult Social Care because her dressings were not being changed daily. In addition, Mrs Robert’s family raised concerns as did the hospital nurse responsible for Mrs Robert’s care. The report notes that insufficient dressing changes for a sacral sore can lead to localised and systemic infection.

Mrs Robert's family were told on several occasions that the nursing team did not have time to change her dressings. On 17 May 2023 a nurse did not attend to care for Mrs Roberts due to demands upon the District Nursing Team. The team offered instead an out of hours visit that would have disturbed Mrs Roberts and her family from sleep and so this was not accepted.

The Coroner noted that there were ongoing staffing issues within the District Nursing Team and that though a number of steps had been taken to address the issues identified by Mrs Robert’s case, there remains residual staffing shortages in the District Nursing Service the Trust is unable to resolve without a change of approach nationally.