Edith Jones

On 23rd October 2025, I commenced an investigation into the death of Edith Jones born on 22nd May 1932. 

The medical cause of her death was determined at inquest to have been: 
1)(a) heart failure on a background of an infected Grade 4 sacral pressure ulcer II Chronic kidney disease, Hypertension, Coronary Artery Atherosclerosis, Frailty

At the end of the inquest, I recorded the following Narrative Conclusion:  Died from natural causes exacerbated by the lack of oversight and management of the pressure ulcer in the community by the District Nursing Team.

Edith May Jones had limited mobility and a number of underlying health  conditions including heart failure. She showed signs of sacral moisture damage  and the Hyde district nursing team became involved in her care. By 12th August  2025 the wound was showing signs of slight improvement. Visits were reduced to weekly. The clinical rationale was not documented. It should have been. On 16th  August 2025 she was visited and the wound had deteriorated. The next visit was  scheduled for 21st August. The rationale for the delay until the next visit was not  documented. It should have been. On 18th August the family requested an urgent visit due to concerns regarding the sacral wound. The visit did not take  place until 19th August. There is no documented rationale for the delay in  attending. This should have been documented. On 19th August the District Nurse who attended did not view the sacral wound. They should have. On 20th  August the family raised further concerns about the wound and were told a  District Nurse would visit on 21st August. On 21st August the dressing was  changed. The wound was found to have deteriorated to a large ungradable  pressure ulcer since the last time there had been any input on 16th August. On  22nd August and 23rd August the nurses attending did not document their  observations of they wound. They should have. By 25th August the wound had  deteriorated further. By 26th August she had Deteriorated further. On 29th August she was admitted to Tameside General Hospital and treated for an infected stage 4 pressure ulcer. Despite being given intravenous antibiotics for 5 weeks she did  not improve and became increasingly frail. She died at the Stamford Unit on 17th  October 2025. A post mortem concluded that she had died from heart failure  exacerbated by the strain of dealing with the infected grade 4 pressure ulcer.

In my opinion unless action is taken to address the above concerns then there is  a significant risk of future deaths and I believe each of you have the power to take such action.