Learning from Experience Database - Serious Case Reviews

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Mrs D (Coventry)

Mrs D died following an accident and a brief period of treatment in hospital and the community. The injury which Mrs D sustained falling from her wheelchair in the summer of 2011, resulted in a period of hospitalisation and a decision to treat her neck injury using a supporting neck collar. The collar itself caused friction to her skin resulting in the formation of a pressure ulcer. This ulcer in turn eventually became infected and Mrs D died as a result of the septicaemia, or infection based blood poisoning which it caused. Mrs D was an elderly woman with a number of disabilities and health concerns prior to the incident which ultimately led to her death. She was extensively supported by her family. This serious case review examines the underlying causes of Mrs D’s death and provides recommendations to reduce the likelihood of their recurrence in the future.

Professional learning:

  • There were some significant shortcomings in the assessment, care, treatment and services provided and some missed opportunities for closer working between agencies providing care.
  • A positive and proactive approach to joint working is in the best interests of those receiving services, as well as basic standards of care being effectively and comprehensively delivered.
  • Families should be listened to as much as necessary, and have the opportunity to make a contribution within formal care environments alongside health and social care professionals.
  • Staff should ensure that carers have an opportunity to express concerns and have those concerns responded to in a timely fashion.

2013 Serious Case Review regarding Mrs D (Coventry)