Patient dies after staff ignore sore risk - coroner

A coroner has criticised care staff after a largely immobile dementia patient was not repositioned until she developed sores which contributed to her death.

Ramona Harbott was discharged from hospital to Windmill Manor Care Home in Oxted, Surrey, on 27 December 2024 because of her increasing care needs.

Mrs Harbott developed sores at Windmill Manor, one of which became an unstageable necrotic ulcer by the time she was returned to hospital. Assistant Surrey coroner Susan Ridge said that despite treatment, "the damage had already been done".

Barchester Health Care Limited, which runs the care home, said it would not be commenting before responding to the coroner's report.

Ms Ridge said Mrs Harbott was a frail, elderly lady who had dementia, diabetes mellitus and "very limited" mobility.

Mrs Harbott had a high risk of developing sores but was not regularly repositioned until 13 January, some 16 days after moving into Windmill Manor, when staff noticed redness to the sacral area - the very base of the back and top of the buttocks.

By 20 January, the redness had developed into a category two sacral sore, and four days later Mrs Harbott was admitted to East Surrey Hospital after her overall condition began to deteriorate.

Ms Ridge said: "On admission to East Surrey Hospital, she had high infection markers, a cough, and fever. Mrs Harbott was also found on admission to hospital to have a significant unstageable necrotic sacral pressure sore."

This meant it was not possible to confirm the severity of the sore because it was covered by dead skin.

Ms Ridge added: "Although actively treated for both the sacral sore and her infection, Mrs Harbott continued to deteriorate and died in East Surrey Hospital on 19 February 2025.

"She died from sepsis having contracted pneumonia. The serious sacral sore which was well established by the time she was admitted to hospital more than minimally contributing to Mrs Harbott's death as it contributed to her overall deterioration and lack of physiological resilience."

Ms Ridge said although the court was told Windmill Manor had policies for preventing and managing bed sores, it had not been followed by care or nursing staff.

She said she also remained concerned that apparent improvements made by Barchester Health Care were yet to be completed and audited.

A Barchester spokesperson said: "Our sincere condolences are with the family at the time.

"We respect the coroner's report and will respond ahead of the deadline as requested. As a result, we cannot comment in detail at this time."

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