The conclusion of the inquest into the death of double amputee Janet Prince was heard on Friday, 14 February 2020 at Nottingham Coroners’ Court.
Eighty-year-old Mrs Prince, who was prone to bed sores due to her limited mobility, died in January 2019 – 18 months after she was taken to the Queen’s Medical Centre in July 2017.
During her stay in the hospital, she developed three pressure ulcers, which deteriorated, leading to Mrs Prince possibly contracting osteomyelitis – a rare and serious infection of the bone that can cause deep and painful sores – although this cannot be confirmed without a bone biopsy, which was not suitable for Mrs Prince due to her age and ill health.
When an infection was detected in late November 2017, it was too advanced for Mrs Prince to undergo surgery, which would have treated the infection. In October 2018, Emma Thirlwall, Mrs Prince’s daughter and carer of 19 years, had issues obtaining a prescription for her mother due to the long-term use of antibiotics to treat open wounds going against the advice of microbiologists.
Conclusion of the inquest into the death of Janet Prince
Nottinghamshire assistant coroner Gordon Clow recorded a narrative conclusion, stating that Janet Prince died of natural causes contributed to by neglect. The coroner also found that extremely serious pressure sores, which were avoidable, were the primary cause of Mrs Prince’s death.
“This is a truly tragic case and the circumstances surrounding Mrs Prince’s death are extremely distressing. Emma had to dress her mother’s exposed bones daily in the lead up to her death, which is something no daughter should ever have to do.
“Emma took hundreds of images on her phone, which were timestamped, that seemed to suggest a correlation between the use of antibiotics and the improvement in the presentation of the wound. However, so many decisions during this time were made by medical professionals who hadn’t seen these images or Mrs Prince and were reluctant to write a prescription. Eventually, Mrs Prince was given a prescription for the antibiotics.
“During the inquest, we heard from Zsolt Hodi, a pathologist at Nottingham University Hospitals NHS Trust, who conducted Mrs Prince’s autopsy. He told the coroner that the pressure sores on Mrs Prince’s body following her death were ‘unusually advanced’ and ‘probably the worst’ he had ever seen in his career.
“The inquest also revealed some extremely concerning evidence of Mrs Prince being deprived of a mattress that was suitable for her needs. The coroner found that the pressure sores started developing while Mrs Prince spent nine hours in the Queen’s Medical Centre’s A&E department in July 2017.
“The coroner accepted that Mrs Prince should have been assessed and placed on a suitable mattress shortly after her arrival to reduce the risk of pressure damage. However, staff failed Mrs Prince by keeping her on a trolley, which was unsuitable for her needs, during her time in the department.
“The inquest was adjourned in October 2019 after the trust asked for the hearing to be delayed until February 2020 in order to file evidence that practices had changed, so that there was no risk of deaths happening in the same circumstances in future. However, no such evidence was filed.
“It is understood that the coroner will be submitting a prevention of future deaths report to Nottingham University Hospitals NHS Trust due to ‘gross and obvious failings’ of care in the nursing department at the Queen’s Medical Centre, specifically in the A&E department, which he considers may happen again in the future.
“Emma and her family hopes that what happened to Mrs Prince will raise awareness and understanding of pressure sores, so that her death serves to lessen the chances of her tragic story being repeated. We are currently working with Emma and looking into whether or not legal action against the hospital is appropriate.”
Emma Thirlwall added:
“My mum was paralysed from the waist down after a spinal stroke in 2000 and had her legs amputated in 2008 and 2013. But this did not prevent her from living a fun and active life. She was one of a kind – despite being a double amputee, she never complained and was always positive.
“It’s been very difficult to try and adapt to life without my mum. I was her full-time carer for almost two decades, so I was always by her side. She wasn’t just my mum; she was my best friend and we were a part of each other.
“My mum’s death was extremely traumatic. She was in so much pain and covered in sores that completely exposed her bones, which I had to dress daily. It was heart-breaking to see and hear her in agony. She was sick, lifeless and her leg stumps had started to turn black. Those images will stick in my mind forever, and that’s something no daughter should ever have to deal with.
“I believe that pressure ulcers need to be taken more seriously to prevent something like this from happening again. One size doesn’t fit all when it comes to caring for a patient. Everyone is individual, and policies and procedures should be adapted to deal with different needs.”