MORE deaths could follow if action is not taken after an elderly patient developed a "significant" pressure sore in hospital, a coroner has warned.

An investigation was opened into the death of George Edward Griffiths in May 2022, the Prevention of Future Deaths report submitted by Herefordshire coroner Mark Bricknell said, with an inquest on June 14 recording a narrative conclusion.

Mr Griffiths had been taken to Hereford County Hospital's accident and emergency department by ambulance on February 1, 2022, the report said.

He was admitted to the hospital for treatment after being diagnosed with an acute kidney injury, gastritis, poorly controlled diabetes, and infected toes. 'Profound' metabolic acidosis (a build-up of acid in the body) was also noted on a blood test, the report said.

But while in hospital, Mr Griffiths developed hypernatraemia (high sodium in the blood) and sepsis and was also treated for hyperosmolar hyperglycaemic state (very high blood glucose) and investigated for Fournier's gangrene (an acute necrotic infection), and was transferred to the intensive care unit for further care and treatment.

He was later stepped down to a ward, where he developed and was treated for delirium and Covid.


Mr Griffiths was then transferred to an elderly care ward after his "long and complicated" admission, by which time he had developed a "significant" pressure sore and C-diff, the report said.

Mr Bricknell said doctors believed the pressure sore, which had developed during his hospital stay, had contributed to his death.

Noting his concerns in the report, Mr Bricknell said Mr Griffiths appeared to have been in the accident and emergency department for more than 40 hours, during which time his shoes were not removed, and that a necrotic toe was apparent without evidence of appropriate management or referral.

A skin inspection confirming all areas were intact had been carried out on his admission, Mr Bricknell said, but there was no evidence of preventative care during his time in accident and emergency or in the acute medical unit.

Acknowledgement of pressure damage was noted on February 8, but no reassessment took place until February 20, with a consequent failure to implement pressure-relieving measures, the report said, noting that "pressure area care training is not mandatory within Wye Valley NHS Trust".

"In my opinion there is a risk that future deaths will occur unless action is taken," the coroner said in the report, which has been sent to Wye Valley NHS trust and the chief coroner.