Karen Day

I am Emma Mather, Assistant Coroner, for the Coroner area of West Yorkshire (East).

On 29 July 2022 an investigation was commenced into the death of Karen Lesley Day, aged 58. The investigation concluded at the end of the Inquest on 28 November 2024. The medical cause of death was 1a) Septicaemia 1b) Soft tissue infection, Pneumonia 1c) Traumatic Laceration II) Raynaud’s disease. The conclusion of the Inquest was: Accident.

Karen Lesley Day sustained a small laceration to her left lower leg in 2021 when she injured it  on a van. She sought help from her GP practice to manage the wound in June 2021 and  appointments with the practice nursing team commenced. Over the course of the following 11  months, Karen attended multiple appointments where the appropriate lower limb framework was not followed and opportunities to escalate Karen’s deteriorating wound and overall  condition were missed. Karen was admitted to hospital on the 26 th May 2021 and was treated  for an acute infection following which she was discharged to the care of the district nursing  team. The lower limb framework was not used consistently and opportunities her increasing  deterioration was not fully recognised and escalated. She was admitted to hospital on the 12 th July 2022 where she was, by this point, extremely unwell. The hospital commenced active  treatment to which she did not respond and care was orientated towards palliation and comfort. Karen died on the 14 th July 2022.

During the course of my investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) During the course of the inquest I heard evidence that the GP practice did not follow the  lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate  concerns around the deteriorating wound or consider appropriate measures to support the deceased to either self-manage her wound with an at home compression bandaging kit, or to support her to attend appointments on a more regular basis. I am concerned that the  practice was unable to provide assurance that the same situation could not occur again. (2) During the inquest I received evidence that the practice had not carried out any internal  investigation in relation to this death and the practice accepted it should have done. I am  concerned that the practice does not have adequate systems in place to ensure that  patient safety incidents are reviewed in a timely way to allow lessons to be drawn from the findings.

In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.