Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SRS), a low-level care facility. Following multiple falls and hospitalizations in late 2016, she was identified as high-risk for pressure ulcers and severely malnourished (BMI 14.4). Despite being discharged back to Crofton House with documented pressure ulcer risk, the facility failed to escalate her care or provide promised pressure-relieving equipment. Her GP attended infrequently (monthly). By July 2017, her pressure ulcer had progressed to stage 3 with infection before hospital transfer. Clinical lessons include: SRS facilities must recognise when residents' care needs exceed their capacity and escalate appropriately; GPs should facilitate advance care planning and coordinate specialist wound care; and early geriatric reassessment following acute deterioration is essential to guide appropriate placement.