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.
‘Pillar to post’
Once she left hospital Ms Prince’s wounds “did not completely heal at any time”, said Mr Clow, who praised Ms Thirlwall for providing her mother with a standard of care “considered to be much higher than would ordinarily be possible in the community” by district nurses visiting her.
Ms Prince’s condition was extensively monitored up to her death, with the “complex and difficult” nature of her wounds requiring a number of specialists to work together.
“It proved hard for Mrs Prince to get a clear treatment plan and both she and some of the clinicians involved felt that she was being passed from pillar to post,” Mr Clow said.
Ms Prince’s health declined in December 2018 and she died at home the following month.
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 be 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”.
Ms Thirlwall said her mother’s death was “extremely traumatic”, adding she was “one of a kind” who never let her injuries stop her from living “a fun and active life”.
“It was heartbreaking to see and hear her in agony,” she said.
“She was sick, lifeless and her leg stumps had started to turn black.
“Those images will stick in my mind forever, and that’s something no daughter should ever have to deal with.”