Nikolas Clarke represented the local authority social services' department in an inquest concerning IMT, an 82-year-old woman, who died in May 2020.
IMT used a wheelchair after her leg had been amputated.
From February 2020 , she was being supported at home by a private care agency contracted by the local authority as part of a care package.
Background to the inquest
In January 2020, IMT was admitted to hospital following a fall and found to have a grade 4 sacral pressure ulcer. In February, she discharged herself from hospital despite advice she should go to inpatient rehabilitation.
The local authority put in place a care package for her at home until April when managing without care was trialled. At that time, IMT declined to be assessed for long-term care. She also declined advice to be nursed in bed or to go to hospital when a specialist hoist was unavailable to lift her at home.
On 5 May 2020, her nephew called an ambulance after he found her in considerable pain and drifting in and out of consciousness.
IMT was found to have a contaminated grade 4 sacral pressure sore reaching to muscle and bone, sepsis and other health complications. She was given antibiotics.
However it was determined that she was unlikely to survive. She died a couple of days later.
The coroner’s findings
The coroner found no evidence of causative failings by the local authority and made no report for Preventing Future Deaths.
He gave a short narrative conclusion saying that IMT had declined to follow important advice which would have reduced the risk presented by the grade 4 ulcer that eventually led to her death.
He was satisfied that nothing done created a cause for concern that this was an unnatural death in terms of the delivery of care or neglect. He found the care delivered was of a good standard by the organisations involved.
Everything was done properly and was carefully documented.