Woman’s death linked to lack of district nurse wound care visits

A hospital has acknowledged concerns raised in a coroner’s report about how a lack of district nurse wound care – driven in part by staffing levels – contributed to the death of an elderly woman.

The response follows a report which found that district nurse numbers were ‘thin on the ground’ at Whittington Health NHS Trust at the time of a woman’s death.

Mary Fitzpatrick, aged 86, had required regular visits from district nurses to dress her sacral wound sore and change the dressing.

Ms Fitzpatrick was discharged from the Whittington Hospital in London on 29 January 2025, and then treated by the Islington Central district nursing team from Whittington Health.

Her sacral pressure sore was assessed as a category two on 1 February, the coroner found, but by 24 February was deemed a category four sore.

Following the worsening of her sore, Ms Fitzpatrick was readmitted to hospital on 27 February after which her condition worsened and she died.

Responding to the report last month, the trust said ‘the care of Mrs Fitzpatrick fell short in a number of ways’.

Insufficient wound care visits

In a prevention of future deaths report, published last month, the area coroner for Inner North London, Mary Hassell, said Ms Fitzpatrick’s wound was not dressed ‘with appropriate frequency’.

‘Sometimes they attended as planned, but sometimes they did not attend and sometimes they attended but did not change the sacral dressing,’ she wrote.

Ms Hassell said it ‘remains unclear’ why Ms Fitzpatrick had not received more dressing visits but describes being told that district nurse numbers were probably ‘thin on the ground’ by the deputy manager of the Islington Central district nursing team.

Responding to the report the chief medical officer (CMO) at Whittington Health NHS Trust said district nurse staffing levels were affected by long-term sickness during the period addressed in the coroner’s report.

This included one staff member who had been on leave for around four months, and two other staff members who were on annual leave.

‘We acknowledge the coroner’s concern regarding the frequency and appropriateness of district nursing visits and dressing changes,’ the CMO wrote.

In their response, the Whittington’s CMO explained that agency and bank nurses were used to ‘maintain service cover’ over the time that Ms Fitzpatrick was receiving care, including when a bank nurse undertook a joint visit to Ms Fitzpatrick on 8 February.

Lack of preparation

The report describes the lack of understanding of Ms Fitzpatrick’s case by the district nursing team’s deputy manager, including being unacquainted with the ‘basic elements’ of Ms Fitzpatrick’s medical records and other details following her death.

‘When I took evidence from the deputy manager of the Islington Central district nursing team, I was very forcibly struck by the lack of reflection undertaken since Mrs Fitzpatrick’s death, about the district nursing care, even when preparing to give evidence at inquest,’ it reads.

Responding to these concerns the CMO said: ‘We acknowledge the coroner’s concern that there was insufficient reflection on the quality of district nursing care provided to Mrs Fitzpatrick, both during her deterioration and in preparation for the inquest.

‘We accept that the deputy manager who attended court was not adequately prepared to give evidence, which fell below the expected standard.

‘We also recognise that our communication with Mrs Fitzpatrick’s family – both in person and in writing – did not provide the clarity, explanation, or candour they deserved, and that this contributed to their distress,’ they said.

What are the next steps?

Whittington Health NHS Trust said it was introducing a series of improvements to strengthen learning from patient deaths, enhance staff support, and improve compliance with the Duty of Candour across its services.

Mortality reviews extended to community services

The trust’s mortality review process, previously focused on inpatient care, will now include all patient deaths in community services. This will ensure learning from every case, wherever care is delivered.

Wider sharing of learning from deaths

Findings from incidents, feedback, inquest outcomes, and Prevention of Future Deaths (PFD) notices will continue to be discussed at staff meetings and will now also be shared with all community staff.

More support for staff in coroner’s court

Training and guidance are being strengthened for staff involved in writing statements and attending coroner’s court. The legal services team will provide support, and new guidance is being developed with the associate medical director for learning from deaths. the trust is also reviewing the seniority of staff who attend court to ensure evidence is as useful and informative as possible.

New duty of candour proforma

A new Duty of Candour proforma has been developed to capture professional and written communications clearly and completely. This will help improve tracking and auditing across the trust. Implementation is expected by December 2025, with results presented to the Quality Governance Committee.

Ongoing training and audit

Regular audits and refresher training will reinforce understanding of the Duty of Candour. Training completion rates will be monitored by the patient safety team and reported quarterly to the Quality Governance Committee.

Source: The Whittington Health NHS Trust

Care being ‘left undone’

Chief executive of the Queen’s Institute of Community Nursing (QICN), Steph Lawrence, recently said district nursing care was increasingly ‘not being done’, leading to what she described as ‘community corridor care’.

Responding to the Care Quality Commission’s (CQC) State of Care report last month, Ms Lawrence warned that a lack of district nurses would be seen as a growing issue in coroner’s reports.

‘There are increasing numbers of prevention of future deaths notices being issued in relation to community nursing services.

‘There are also increases in harms being recorded, for example, an increased incidence of pressure ulcers,’ she said.

In June, a report from the QICN described how district nurses were up against increased workloads and more complex patient needs.

It highlighted how more teams are carrying bigger caseloads, with the number of district nursing teams working with 600 or more patients having risen by 16.2% in 2023.

Earlier this year, early findings from a report by the Nuffield Trust revealed that the number of district nurses working in the NHS in England has fallen by 43% between 2009 and 2024.

Latest findings from the report have shown that over a quarter of district nurses were lower than Band 6, while a growing proportion of staff working within district nursing teams are not registered nurses.