Hospital's 'gross failings' led to pressure sores death

A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment.

Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019.

Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH).

Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one.

"No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said.

Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone".

Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces.

Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH.

NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case".

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Source: BBC News, 14 February 2020