Norma Lockton was 90 years old when she died whilst in the care of Jubilee Court Nursing Home.

Having been in relatively good health for her age, Norma had started to become less mobile in early February 2020. Assistant Coroner Elizabeth Didcock found that the increased risk of skin damage that would result from a reduction in Norma’s mobility was not recognised by Jubilee Court staff or evidenced in her care plan. In addition, staff had failed to follow the district nursing team’s instructions in relation to a basic skin care regime which would have reduced the risk of pressure sores. Ultimately, a wound had developed behind Norma’s left knee by 29th February. That wound then became infected and, due to the care staff’s failure to follow the recommended regime, it went unseen. Despite the presence of clear indications that an infection had developed in Norma’s leg, no medical assistance was called for until she had advanced cellulitis and systemic sepsis in the afternoon of 2nd March. By which time, antibiotic and fluid treatment was ineffective. Norma died on 4th March.

The Inquest concluded that the cause of death was sepsis, and that the wound behind Norma’s knee was the source of that infection. Crucially, had care staff followed the skin care instructions provided by the district nursing team, Norma would have survived.

Following submissions on behalf of the family, this failure to provide basic care led to the finding that Norma’s death was contributed to by neglect. A Prevention of Future Deaths Report was also issued to Jubilee Court in recognition of how serious the failings were, and the risk posed to residents in the future.

Joshua Yetman represented the family during this 3-day Inquest. He was instructed by Lime Solicitors.

The Coroner’s conclusions were also reported by local press which you can view here.


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