NHS trust ordered to take action over pressure sore death

Myra Maxfield was recovering at the Haywood Hospital after surgery, but was to be readmitted to the Royal Stoke University Hospital three times before her death

The area coroner for Stoke-on-Trent has demanded action after a patient died after developing a pressure sore in hospital.

Myra Maxfield, 89, fell and broke her hip at home in September 2021.

She died six months later from a combination of factors, but the coroner expressed concern a specialist hospital team was not available at weekends.

University Hospital North Midlands NHS Trust said all staff were trained to manage and prevent pressure sores.

In issuing a Regulation 28 report, assistant coroner Miss Serrano called on UHNM to take action to prevent future deaths.

The inquest heard Mrs Maxfield fell at her home in Rode Heath and was recovering well after surgery, and so was discharged 11 days later to Haywood Hospital.

During her stay there, she developed a bed sore which deteriorated to stage 4 - the worst kind.

She also suffered a bleed in the upper part of her digestive system and was admitted to the Royal Stoke University Hospital.

Surgery to stop the bleed was successful, but by December the ulcer had infected her bone.

Substantial delays

Mrs Maxwell died in March 2022, with the coroner recording a narrative verdict, listing the cause of death as an infected pressure ulcer, combined with upper gastrointestinal bleed, frailty and the fall.

Miss Serrano said it was crucial that at-risk patients saw the tissue viability team - specialists in treating wounds - within six hours, but because there is no team available over the weekend it led to substantial delays in patients being seen.

She told the hospital trust: "In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action."

Copies of her recommendation have been sent to the chief coroner and to the family of Myra Maxfield.

In law, the trust has until 15 December to respond and has to set out a timetable for taking action or explain why no action is proposed.

UHNM Chief Nurse, Ann-Marie Riley said that preventing avoidable pressure sores was an important measure of quality in hospital.

She said: "UHNM does not have a weekend tissue viability service at Royal Stoke University Hospital, this is in line with many acute trusts nationally.

"However, training is provided to all staff and there are pathways, policies and guidance to support front-line clinicians with pressure ulcer prevention and management out of hours."

She said that the trust would respond by the coroner's deadline.