Finding into death of Yvonne Eddolls

68y · Female·Sepsis (palliated)

Ms Eddolls, a 68-year-old woman with intellectual disability and complex medical conditions, died from sepsis secondary to pressure ulcers while in specialist disability accommodation. She developed sacral and heel pressure ulcers following relocation to new accommodation. Despite GP review in November noting early pressure areas and advice to prevent deterioration, the ulcers progressed and became infected with MSSA osteomyelitis. She was hospitalised in December with sepsis, acute kidney injury, hypernatraemia and malnutrition. The coroner found death due to natural causes. Clinical lessons include: early recognition and aggressive prevention of pressure ulcers in immobile, vulnerable patients; ensuring adequate nutritional intake in patients with communication difficulties; maintaining continuity of medical records during care transitions; and timely involvement of specialist teams when complications develop.