A FRAIL woman who died after her bedsores became infected may have lived had staff at her care home appreciated the severity of her condition, an inquest heard.

Retired shorthand typing teacher Hazel Fryers died at Princess Lodge Care Centre in Curie Avenue, Old Town on March 22 this year.

Staff were aware that she had developed bedsores in October but waited until the skin was broken – Grade 3 – before calling a tissue viability nurse for advice.

In the early stages of her suffering the inquest heard that Mrs Fryers was only given paracetamol to alleviate her pain.

Peter Singleton, Deputy coroner for Wiltshire and Swindon, said given the circumstances of the 83-year-old’s death he did not feel it appropriate to record a verdict of natural causes.

Mr Singleton said the “highly preventable death” came about by sepsis caused by bedsores and ischemic heart disease and dementia.

“There was a delay in treatment being sought when the sores were noticed that could have affected the outcome,” he said. “The significance was not duly appreciated and action to prevent death by earlier action was not taken.”

Widowed Mrs Fryers moved into Princess Lodge in May 2009 after being discharged from Great Western Hospital following a hip replacement. Until then she had been cared for by her son Raymond who became her full-time carer when she was diagnosed with dementia in 2005.

By the time Mrs Fryer moved into Princess Lodge her dementia had taken told to such an extent she was unable to talk, wash or care for herself and was incontinent.

She was cared for at the home mostly in a pressure bed – designed to reduce the risk of bedsores – or her armchair, where she sat on a pressure cushion.

But the bed was only effective while set to the same weight as the patient and on several occasions tissue viability nurse Jane Hodgson found it set at 128kg – more than twice the weight of Mrs Fryers, who was just 60kg.

“It’s worse than not having the bed there at all,” she told the inquest.

Mrs Fryer had several sores, some of which had become necrotic – where the flesh begins to rot – and while they had improved the month she died, by March 20 she took a turn for the worse and died two days later.

Explaining the change in the appearance of the wounds within the two weeks between her visits in March, nurse Hodgson said: “The left hip had gone from 6x5cms to 10x11cms and the tailbone had gone from 4x3cms to 12x8cms.

“When you have necrotic tissue I would expect the wound to get a bit bigger,” she said. “To a certain extent you need the badness before you get the goodness.”

She added: “I would have preferred them to call me when the wound was Grade 1 or 2.

“These sores would have taken a long time to heal.”

Nurse Hodgson said on her last visit she could smell Mrs Fryer before she had seen her and was instantly aware that her wounds had become infected.

“I didn’t see Hazel first of all but I could smell the odour and I asked the staff if it was her wounds that were smelling and was it sepsis,” she said.

“My specialism is tissue viability and that’s an odour I have smelled before.”

Care home manager Ann Martin said all staff maintained the care plan set out by Mrs Fryers family and followed policy.

Speaking after the inquest Paul Ware, chief operating officer of Life Style Care PLC, the management company for Princess Lodge, said: “We work closely with the CQC (Care Quality Commission) and will take any advice given to us by them about how to avoid any occurrence or any problem deemed to have occurred in this particular case. If there are lessons to be learnt we will learn them.”

Mrs Fryers’s adopted sister Pauline Sypher said: “We hope now to draw a line under this.”