Care home 'neglect' contributed to woman's death

The coroner said he would issue a prevention of future deaths report

A nursing home's failure to seek specialised treatment for one of its residents amounted to neglect and contributed to her death, a coroner has said.

Beatrice Smith, 88, was a resident at Riverside Care Home in Maryport, Cumbria, and died after developing sepsis from an ulcer on her right foot.

An inquest at Cockermouth's Coroners' Court heard Mrs Smith's ulcer had deteriorated over time, but coroner Robert Cohen said the home had failed to "properly manage" her wounds, contributing to her death.

Care home manager Sarah Nicholson apologised to Mrs Smith's three daughters during the hearing and said lessons had been learnt since her death.

Mr Cohen returned a narrative conclusion and said he would be issuing a prevention of future deaths (POFD) report to the care home owners - a document sent when a coroner thinks action is needed to protect lives.

He also criticised aspects of the care Mrs Smith received while a patient at the Cumberland Infirmary in Carlisle, though he said the trust managing the hospital had addressed many of his concerns during evidence.

'Shocked at her state'

Mrs Smith had been found on the floor of her home by carers in September 2024, having lain there for a long time, Thursday's hearing was told.

She spent the following five months at the Cumberland Infirmary, where she was treated for a large ulcer to her left leg, which went from her thigh to her ankle.

The coroner heard evidence that before being discharged to Riverside, the wound had almost completely healed and there were no signs of infection.

However, Mrs Smith had in the meantime developed an ulcer on her right heel.

Ms Nicholson told Mr Cohen the complexity of Mrs Smith's wounds had not been clear when they agreed to take her on as a resident and, had it been, the home might have requested more information "so we could have been better prepared".

The coroner raised concerns about some aspects of the care Mrs Smith received in hospital

The court heard Mrs Smith's wounds had been deteriorating over time.

On 17 April, her daughter visited and was left "shocked at the state she was in" and an on-call doctor was summoned.

In a statement read to the court, she said her mother was slumped on a chair and had no dressing on her wound, which was weeping pus on the floor.

Ms Nicholson said advice had been sought from Mrs Smith's GP two days before, as she had been refusing her medication.

A podiatrist had also previously been to visit Mrs Smith but they could not make a further appointment as it was a bank holiday.

The coroner said evidence showed when the home called again after the weekend, staff failed to send further images of Mrs Smith's wounds to help the podiatrist give advice.

'Nothing has been done'

On 23 April she was found unresponsive in her room. She was taken to the West Cumberland Hospital in Whitehaven, where she died.

Mr Cohen repeatedly asked Ms Nicholson what actions had been taken to address concerns identified in Mrs Smith's care.

Ms Nicholson apologised to the family, before responding to the coroner saying more could have "possibly" been done to help Mrs Smith.

She said no extra training had been made available to staff, that all training was "up to date" and that the care home had been taken over by a new provider.

Mr Cohen said: "There have been some pretty stark issues here, I'm surprised no steps have been taken to tackle those head-on, has anything been done?"

She replied: "No, not at the moment."

In his conclusion, Mr Cohen said the lack of additional training on wound treatment gave rise to "a real risk" of future deaths.

Hospital care delays

Mr Cohen said he would not make a POFD report for the care she received at the Cumberland Infirmary last September, though he had concerns about aspects of her care.

The court heard that when Mrs Smith was admitted, a specialised team of tissue viability nurses (TVN) assessed her large leg ulcer.

While efforts were being made to treat the infection with antibiotics and dressing changes, Mr Cohen said "an oversight" by nursing staff on Elm A ward meant they did not seek further help from the TVN team for one month.

"Nursing staff on the ward believed the TVN team would return and assess her wound regularly, but in fact, the policy is that they only attend if specially requested," Mr Cohen said.

Mrs Smith later died at the West Cumberland Hospital

The coroner read evidence from a nurse on the TVN team who reviewed Mrs Smith a month after her admission.

She described the wound as "necrotic, foul smelling and with green discharge", and filed an incident report which raised concerns about the delay.

Elm A ward manager Michelle Beck said there had been "a lot of different nurses" dressing the wound and said there was a "lack of confidence in wound care".

She blamed "a lack of knowledge" and the misunderstanding over the TVN's involvement for the delay in the referral.

Ms Beck told the court action had since been taken, including additional mandatory training for nurses, a reconfiguration of staff on the ward and the inclusion of wound care plans as part of handovers.

Mr Cohen said the fact the trust had taken "active steps" to address the issues, meant a further POFD report would not be required.

The court heard a tribute to Mrs Smith by one of her daughters, who described Mrs Smith as a "strong, independent, proud mother" who would do anything to help her family.