“(brief summary of matters of concern) A”

The coroner’s concerns

(brief summary of matters of concern) A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case. Regulation 28 – After Inquest Document Template Updated 30/07/2021 B. Mrs Divall was referred to the Physiotherapy Department 2 weeks after admission but was rarely assisted with mobilisation and left to sit out in her chair for long periods. Action should have been taken to encourage Mrs Divall to mobilise more often in an attempt to rehabilitate her after her surgery. C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary. D. The Discharge Summary was misleading to the District Nurses who were unaware of the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did not make clear that Mrs Divall had been discharged for end of life care. E. The RCA was insufficient and did not address all of the issues surrounding Mrs Divall's care nor did it properly address those issues it did consider.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0263

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0