An inquest into the death of 88 year-old Beatrice Smith concluded at Cockermouth Coroner’s Court last week, hearing that her condition had “deteriorated seriously” in the care of Riverside Court.

Mrs Smith had been admitted to the Cumberland Infirmary in Carlisle in September 2024 following a fall and long lie, in which she had developed a serious ulcer on her left leg.

The Cumberland Infirmary Hospital in Carlisle(Image: Archive)

She was discharged from hospital to Riverside Court in February 2025, having developed further ulcers, but the inquest heard that her condition deteriorated and an ulcer on her right heel became badly infected.

Mrs Smith died in West Cumberland Hospital on April 23, having been admitted that day with sepsis.

Read more

A report published this week outlined failings in Mrs Smith’s care at Riverside Court, urging the provider, Harbour Healthcare Limited, to take action to prevent future deaths.

In his report, coroner Robert Cohen wrote: “Neglect, being the failure to seek specialist care and wound management for Mrs Smith following her deterioration on April 15 2025, contributed to her death.”

Concerns were raised in Mr Cohen’s report that Harbour Healthcare Limited did not carry out an internal investigation when a safeguarding referral was made regarding Mrs Smith’s condition in April.

An ulcer on Mrs Smith’s right knee was “not always properly dressed” and Riverside Court did not seek specialist attention when her condition worsened from April 15 onwards.

Mr Cohen also expressed concerns that additional training has not been carried out at Riverside Court following the incident.

Cockermouth Coroners’ Court on Station Road.(Image: Newsquest)

A spokesperson for Harbour Healthcare acknowledged the concerns raised by the coroner, telling the News & Star that “safety, dignity, and wellbeing of every person in our care is our highest priority.”

They said: “First and foremost, we extend our deepest sympathy to the family and loved ones affected by this loss. Every death is deeply felt, and we take the coroner’s findings with the utmost seriousness.

“We are currently reviewing the coroner’s report in full and are cooperating fully with the relevant authorities to ensure that all necessary actions are taken without delay.

“Harbour Healthcare acquired Riverside Court in April 2025 and have implemented robust and preventative processes, this includes reviewing lessons learned and route course analysis. 

“We are determined to learn from this case and further strengthen our practices to ensure the highest standards of care and safety are consistently upheld across all our services.”

The company has 56 days to reply to the coroner, outlining actions to prevent similar cases in the future.

Mr Cohen also noted in his report that an ulcer on Mrs Smith’s left leg went untreated by tissue viability nurses for one month during her stay in the Cumberland Infirmary in late 2024 and early 2025, but that her condition began to improve prior to her discharge in February.

A spokesperson for North Cumbria’s health trust said: “Although the coroner found the delay in re-referral to the tissue viability service at the Cumberland Infirmary did not contribute to Mrs Smith’s death, the Trust undertook an investigation immediately and significant changes have been made at ward level, with work ongoing across the Trust to ensure a consistent provision of high quality care.”

They expressed “sincere condolences” to Mrs Smith’s family.