The coroner said nurses could have prevented the 86-year-old Islington woman’s death if they had regularly changed her bandages
A North London NHS trust is under fire after community nurses failed to properly treat an elderly woman’s injury, which grew into a “gaping open wound” and led to her death in hospital. A coroner ruled that 86-year-old Mary Fitzpatrick would not have died at Islington’s Whittington Hospital in March had her bandages been changed frequently enough.
Mrs Fitzpatrick was first admitted to the North London hospital on 23 January this year, not for medical reasons but because a district nurse did not believe she could move her from a wheelchair to her bed without a colleague – despite this having been done several times in the past. After waiting on a hospital trolley for hours, Mrs Fitzpatrick developed a bed sore. She was discharged from Whittington six days later, only to be re-admitted in February. She died roughly three weeks later.
While the inquest report found that Mrs Fitzpatrick died of natural of causes, Senior Coroner Mary Hassell said her death would not have happened when it did if she had been cared for properly by Islington Central district nursing team. Community nurses had made infrequent visits to her home and did not consistently change the bandages for her wound, which had been classed as a serious injury. Had they done so, she would not have re-entered the hospital and “deconditioned” as elderly patients often do, the coroner said.
Yet despite this, the watchdog found that even in the aftermath, nursing managers had not seriously considered the chain of events that led to Mrs Fitzpatrick’s death. They had also failed to spell out why the elderly widow did not get proper care. “The only explanation I was given was that they were probably ‘thin on the ground’,” Ms Hassell said.
In particular, the coroner was “forcibly struck” by the deputy nursing manager’s lack of preparedness when it came to the inquest. “She had not acquainted herself with some basic elements of the medical records and, whilst in the witness box, changed her mind about what home visits had taken place depending on who asked the question.”
Beyond this, the deputy manager “steadfastly refused to acknowledge gaps in care despite glaring evidence to the contrary, and when this was brought to her attention, she simply stopped answering,” the coroner said. Although the deputy manager had offered a letter of apology to Mrs Fitzpatrick’s family, this was tendered in an “offhand” way.
At the inquest, the coroner judged that the deputy manager appeared to find it difficult to grasp why this did not amount to an apology. “I still do not have a proper understanding of what such a letter was meant to achieve. Much more importantly […] the family did not seem comforted by it,” she concluded.
The coroner said it would be hard for the trust to learn and improve its care if there was “no serious consideration” of why Mrs Fitzpatrick died when she did. Whittington Health NHS Trust has been given until 20 October 2025 to respond to the coroner’s report.
Whittington Hospital was recently ranked 14th out of 22 hospitals in London under the government’s new NHS league table.
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