Law threat over death of woman, 92

An inquest heard Agnes Ashley's sore was so bad within hours of her arriving at hospital it was oozing infected puss.

She died within a month. The Sheffield hearing was told she developed the pressure sore at Eboracum House, a privately-owned care home at Park Grove, Barnsley with 18 residents.

Sores are graded from one to four under a European system and a carer at the home identified Mrs Ashley as having a "graze" categorised as a grade two, when she was admitted to hospital. But within five hours of admission doctors at Barnsley District Hospital had graded it four, the most serious.

A pathologist said she contracted the inflammatory condition sepsis because of the pressure sore. He gave the cause of death as cardiac failure contributed to by "cerebellar infarction with pressure sores".

Mrs Ashley was described as independent and robust before she went into the home in January, 2008. The inquest only dealt with Mrs Ashley's demise from her admission to hospital.

Mrs Ashley's GP, Dr Christopher Bridger, was called by staff at the home on March 16. He found she had been slumped to her left side for two days.

He thought she might have suffered a heart attack and had her admitted to Barnsley District Hospital. Although a carer at the home knew of the pressure sore earlier that day it was not reported to the hospital on admission.

When she was discharged back to the home a day later, district nurses re-dressed the wound every day and staff ensured Mrs Ashley was turned when she slept, but she deteriorated.

The doctor found her very ill on April 6 and she was readmitted to the hospital. She died six days later.

Consultant physician at the hospital Dr Mohammed Malik said the grade four sore was noted and she was given antibiotics and re-hydrated before being sent home.

Tissue viability nurse Susan Irvine who examined the sore at hospital said such sores could develop within hours.

Andrew Mills, lead nurse in the hospital's medical assessment unit, admitted it was "wrongly assumed" a care package was in place with the tissue viability service when the pensioner was released.

District nurse Sharon Holmes who treated Mrs Ashley after her discharge said: "I have never had a patient turned out of hospital with a grade four wound."

Pathologist Dr Steven Beck said she developed the pressure sore because of her underlying heart condition and everything possible was done for her after her release from hospital.

Assistant deputy coroner Donald Coutts-Wood recorded a narrative verdict, stating that "appropriate arrangements and checks prior to the discharge of someone with a grade four pressure sore were not in place".

Andrew Harrison of Raleys solicitors in Barnsley said: "Mrs Ashley developed a grade four pressure sore, the most severe.

"The inquest may have concluded but this is not the end of the matter for Mrs Ashley's family. We are considering all legal options at the present time."

A spokesman for Eboracum House said: "We were very sorry to hear that Mrs Ashley had died.

"The welfare and suitable care of our service users is always of paramount importance to us and we therefore welcomed the opportunity to assist the coroner and welcomed his verdict."