Jane Bruce

On Seventh May 2020 I commenced an investigation into the death of Jane Lesley Bruce aged 54. The investigation concluded at the end of the inquest on Twenty-Eighth October 2021. The conclusion of the inquest was: Narrative Conclusion - Professional opinion is that Ms Bruce’s changed presentation on the 30th April 2020 was indicative that something was wrong, and her care should have been escalated for medical review. Therefore, there was a missed opportunity to treat sooner. Medical opinion is that had antibiotics been commenced, on a balance of probabilities, the outcome would unlikely have been different. However, medical evidence is that the escalation should have been to the hospital where the impending sepsis would have been identified sooner and on a balance of probabilities the outcome would have been different. The cause of death was established as: I a Sepsis I b Fracture Related Infection Right Tibia I c Fracture Right Tibia, Fibula II Chronic alcohol dependence

Jane Bruce presented to the Leicester Royal Infirmary on the 24th November 2019 with a right lower leg injury following a fall at home. A fracture of the right tibia and fibula was diagnosed and surgically repaired with a circular frame on the 27th November 2019. Ms Bruce was seen as an out-patient in the fracture clinic on the 29th January 2020 when it was identified that the fracture was displaced and treatment with external fixation was not working. Therefore, she underwent further surgery on the 24th February 2020 and discharged home on the 24th March 2020 with wound care to be provided by the community nursing team twice a week. Healing progressed slowly but Ms Bruce appeared to be recovering until on the 29th April 2020 her pain increased rendering her bed-bound and the exudate from the wound significantly increased. Ms Bruce was seen by a District Nurse as planned the following day and informed of the increasing pain, that Ms Bruce was now bed bound and the increasing exudate by Ms Bruce’s carer. The dressing was changed, and the dressing frequency was increased to three times a week. Ms Bruce continued to deteriorate and then presented to the Leicester Royal Infirmary for the last time on the 1st May 2020 with features consistent with sepsis. Despite being appropriately treated at the hospital she died the following day.