Ronald Nelson

I am Miss Sarah Wood, Assistant Coroner, for the coroner area of Nottinghamshire.

On the 4 th of February 2025, I commenced an investigation into the death of Ronald Colin Nelson. The investigation concluded at the end of the inquest on the 15 th of January 2026. A narrative conclusion was given.

Colin died from aspiration pneumonia which was caused by his advanced dementia. His advanced dementia led him to be non-verbal. He became bed bound on the 17 th of October  2024  due  to  a  respiratory  infection  and  developed  pressure  sores  as  a consequence of this. He was treated for grade 2 pressure sores whilst in hospital and when discharged to his care home this deteriorated to a grade 3 and then a grade 4 causing sacral osteomyelitis. There were significant gaps in Colin’s records at the care home and evidence a care plan was not followed leading to the deterioration of the pressure sores and the following infection which led to his final admission to hospital. He was admitted to Hospital on the 16 th of December 2024 for the final time with suspected sepsis. He was diagnosed with aspiration pneumonia on background of advanced dementia. Colin’s pressure sores had deteriorated to category 4 and sacral osteomyelitis was identified on scans. He had very little reserve to fight such infection by this time and died on the 26 th of January 2025 at the Queens Medical Centre, Nottingham. It is my view that a care plan was not complied with and the records from the care home were vague and at times misleading.

During the course of the inquest the evidence revealed a matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows – i)        That there remain potential issues of poor record keeping. ii)       There are concerns over the level of compliance of care plans. In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.

In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.