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InquestIQ

Edith Jones

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15 May 2026Coroner: Alison MutchArea: Manchester South

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Coroner

I am Alison Mutch Senior Coroner, for the coroner area of Greater Manchester (South)

Legal Powers

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DATE OF REPORT 15th May 2026

Legal Powers

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your Response

Your response must contain details of action taken or proposed to be taken,  setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me  any representations regarding publication of your response. These  representations should be made at the same time as the response is provided. I  will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked  for sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published  on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

Action Required

SUMMARY OF CORONER’S CONCERN This report is made in respect of a range of concerns arising from the evidence relating to provision of care by the District Nurses and the GP Practice.

Action Required

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In my opinion unless action is taken to address the above concerns then there is  a significant risk of future deaths and I believe each of you have the power to take such action.

Investigation and Inquest

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On 23 rd October 2025, I commenced an investigation into the death of Edith Jones born on 22 nd May 1932. The medical cause of her death was determined at inquest to have been: 1)(a) heart failure on a background of an infected Grade 4 sacral pressure ulcer II Chronic kidney disease, Hypertension, Coronary Artery Atherosclerosis, Frailty At the end of the inquest, I recorded the following Narrative Conclusion: Died from natural causes exacerbated by the lack of oversight and management of the pressure ulcer in the community by the District Nursing Team.

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