Walter Horton

I am Ms N J Mundy for South Yorkshire East

On 27 January 2025 I commenced an investigation into the death of Walter Colin HORTON.   The investigation concluded at the end of the inquest . The conclusion of the inquest was   Narrative conclusion: Walter Colin Horton died on 10 January 2025 in Benton House Care Home from an infected sacral pressure sore. The risk of the sore becoming infected was  increased due to the absence of aseptic techniques being used in wound management.    1a Sepsis  1b Advanced Sacral pressure sore  II  Ischaemic heart disease

This case relates to the death of a 88 year old male who passed away in a Nursing Home on Fri 10 January 2025. Referred at the request of family due to safeguarding issues and  pressure sores which they felt were associated with the death.  [REDACTED] Pathologist provided a COD as: 1a) Sepsis   1b) Advanced Sacral pressure sore II) Ischaemic heart disease

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –   Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection.

In my opinion action should be taken to prevent future deaths and I believe you Nick Mallaband have the power to take such action.