Inquest is told of neglect concerns after woman died
CHRIS GEE
AREVIEW into the care given to a 70-year-old who died unexpectedly at home was launched after both police and paramedics expressed concerns that she may have been neglected, an inquest heard
Elsie May Pearson, of Barnes Street, Church, Accrington, died on Monday, July 30, 2018, shortly after a visit by a carer.
A hearing at Blackburn Town Hall, heard that Miss Pearson, who lived alone, had been bed bound for around seven months prior to her death and was being looked after in her home by two care agencies and the district nurse team.
She had been receiving regular daily visits from staff employed by health and care organisations in the months prior to her death, including on the day and evening before, and on the morning of her death.
She was found naked and with laboured breathing by her niece, who noticed the downstairs bedroom window was open on the morning of July 30 when passing and decided to call in.
An ambulance was called for and a short time later, as paramedics were attending to retired cleaner Miss Pearson, she entered into cardiac arrest and could not be revived.
The hearing heard from paramedic Paul Jones, who had attended to Miss Pearson.
He said: “I had concerns when examining her as there was a large pressure sore on her lower back which did not seem to have been dressed.”
The inquest heard from Detective Inspector Rachel Higson, who led a police investigation into the death.
She said: “I had concerns because the room had been left with the ground floor window open.
“I examined the wound on her lower back, it was significant.
“I looked at the latest entry from the carer who had visited, it was illegible, I couldn’t read it.”
DI Higson ordered a Home Office pathologist to conduct a post mortem examination. She added that after enquiries and viewing of care providers case records, a decision was made that no crime had been committed.
She said: “The criminal level for a wilful neglect prosecution was not met.”
She said that she passed on information about her concerns to the Care Quality Commission and social services.
Pathologist Charles Wilson told the court that Miss Pearson had several illnesses including an infected gall bladder and pressure sores on her lower back. He said he had concluded the she had died from sepsis as a result of the infection spreading from one or both of those ailments.
The court heard that Miss Pearson was sometimes reluctant to receive support, particularly in checking her skin for tissue breakdown, but was not identified by care staff as a person who self-neglected.
The court heard from senior social worker Shirley Williams who was commissioned by Lancashire County Council Adult Services to conduct a safeguarding review looking into Miss Pearson’s death.
She said the review was a ‘lessons to be learned, no blame’ exercise.
Among the conclusions of the review were Lancashire Safeguarding Adults Board should consider holding a multi-agency, including agency home care staff, workshop to consider learning from the case.
Another recommendation stated ‘contracts with home care agencies should be able to specify that carers have the skill levels to identify serious risks and be sufficiently competent to contact emergency services’.
Coroner James Newman adjourned the inquest until an unspecified later date saying he needed to call additional witnesses, particularly those who knew more about the treatment of Miss Pearson’s pressure sores in the days before her death.