A pensioner died after a sore on his foot was allowed to turn necrotic and he contracted sepsis, it has emerged in a report.
County Durham and Darlington NHS Foundation Trust has been slammed by the coroner for neglect after 84-year-old Stanley Cummins died at his home in September 2022.
His death was due to a pressure ulcer to his heel which became necrotic and led to sepsis - but the coroner believes that more could have been done to help Stanley, and that the Trust must take action to prevent similar deaths in the future.
Stanley's death was "contributed to by neglect", as "the wound was preventable, and the further deterioration of the wound was preventable".
In her Prevention of Future Deaths report, assistant coroner Janine Richards said: "The ulcer was an avoidable injury with appropriate care and management of the known high risk of pressure damage.
"Despite pressure damage being noted to the deceased including to his buttocks and legs there were no comprehensive changes to his care regime, to reduce the risks of further damage occurring, or to manage the pressure damage that had already been caused, becoming worse.
"If the skin had been appropriately monitored it is likely that the early effects of pressure damage to the heel would have also been identified, at which point pressure relief and offloading should have been provided."
The District Nursing team failed to provide appropriate offloading advice and recommendations to Stanley's family and carers following healthcare guidelines or to escalate issues with pressure damage to other services and professionals.
She added that, during an inquest into Stanley's death, she was "not provided with comprehensive evidence that lessons have been learned in relation to the accepted failings in this case".
Now, the Trust must respond to Ms Richard's report by April 29, showing action that has been taken or is set to be taken, as well as a timetable for these improvements.
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