An elderly lady died after a sore on her body turned into a “gaping open wound” as it was not properly cared for, a coroner has found.
Mary Fitzpatrick, 86, died after a pressure sore, a type of ulcer, developed and nurses in Islington failed to treat the injury earlier this year.
A coroner ruled the pensioner’s death could have been avoided if she had not been taken into the Whittington Hospital in Archway.
An inquest into Mrs Fitzpatrick’s death heard that nurses had been “thin on the ground” and Mrs Fitzpatrick was taken into hospital because only one nurse had been able to attend her on January 23.
The nurse had explained she did not feel she could transfer the “small elderly lady” alone without help.
Mrs Fitzpatrick stayed in hospital for six days and was later discharged on January 29.
She was then placed under the care of the Islington Central district nursing team from Whittington Health.
Three days later, Mrs Fitzpatrick’s pressure was assessed as a “category two” injury. But by February 24, it had become a “gaping open wound,” a report looking into Mrs Fitzpatrick’s death revealed.
She returned to hospital on February 27 and died shortly afterwards.
Coroner Mary Hassell wrote in a Prevention of Future Death Report: “It is well recognised that the admission of an elderly person to hospital can be risky and should only be undertaken if really necessary.
“These days, a long wait on a hospital trolley is predictable. Even without that, the elderly are known often to decondition quickly.”
The coroner added that district nurses had not dressed Mrs Fitzpatrick’s wound frequently enough and sometime they had not gone to see her or change her sacral dressing.
“It remains unclear to me why that was so,” the coroner wrote. “The only explanation I was given was that they were probably ‘thin on the ground’.
Coroner Hassell said she was “very forcibly struck by the lack of reflection undertaken since Mrs Fitzpatrick’s death” when she took evidence from the deputy manager of the Islington Central district nursing team.
She added that an apology letter sent to Mrs Fitzpatrick’s family was offered to her daughter “in an offhand way” during a very short phone call.
Coroner Hassell criticised the deputy manager for being poorly prepared for the inquest into Mrs Fitzpatrick’s death, adding that she was not familiar with some basic elements of the elderly lady’s medical records.
The coroner also criticised how the deputy manager changed her mind in the witness box about the number of home visits that had been undertaken and refused to acknowledge there had been gaps in Mrs Fitzpatrick’s care “despite glaring evidence to the contrary”.
She wrote: “It is difficult to see how a trust can learn and improve care if there is no serious consideration of why there was a poor outcome…
“When giving evidence, the deputy manager seemed to be in difficulty understanding what an apology is, naming this a letter of apology but in essence describing a letter of sympathy, emphasising that it was not an admission that the trust had done anything wrong.
“I still do not have a proper understanding of what such a letter was meant to achieve.”
The report named four reasons as Mrs Fitzpatrick’s medical cause of death, including frailty, sacral pressure sore, dysphagia and aspiration pneumonia.
A Whittington Health NHS Trust spokesperson said: “We extend our deepest sympathies to Ms Fitzpatrick’s loved ones for their loss.
“We are currently considering the findings of the coroner in the prevention of future deaths notice, with a view to implementing any appropriate changes to how we provide care, and to ensure that our colleagues are fully prepared to assist coroners in any future cases.”
