A mattress that was wrongly delivered to a 96-year-old woman's home contributed to her death after she developed "significant" injuries to her back, an inquest has concluded.

Joyce Margaret Georgina Rowe was given a new bed frame after she fell out of her bed at her Newtown home where she lived alone in June 2020.

A "miscommunication" between an occupational therapist, a healthcare equipment company and its delivery driver led to Mrs Rowe's air mattress, which helped with her skin's integrity, being wrongly taken away, leaving her with a foam mattress.

An inquest at Welshpool Town Hall heard on Monday (November 14) that the wrong mattress was not identified by carers or district nurses for 16 days by which time Mrs Rowe, who lived with dementia, had developed deep tissue injuries and pressure sores to her lower back and heel.

Her condition deteriorated, and she was taken to the Royal Shrewsbury Hospital then transferred to the Victoria Memorial Hospital in Welshpool for palliative care where she sadly died with her son by side on August 13, 2020.

The medical cause of death was dementia and osteomyelitis, a painful bone infection.

Mrs Rowe’s son Keith said: “I strongly believe if the infection was picked up earlier and had not got into her bones, she would not be in pain, had not gone into hospital and she would continue to be at home and still be here.”

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Recording a narrative verdict, assistant coroner Rachel Knight thanked Mrs Rowe's son for raising concerns about his mother's bed sores, after which her death was referred to the coroner's office.

"I want to say how sorry I am that you've lost your mum in this way,” Ms Knight said.

“Thank you for the respect and dignity that you have shown. I am sorry to meet you in such horrible circumstances."

Powys Teaching Health Board’s lawyer Hywel Evans commended Mr Rowe’s “strength proceeding this today and it’s shone to me from reading the notes”.

The assistant coroner Rachel Knight said she was satisfied "sufficient" changes had been made since Mrs Rowe’s death and there had been a greater awareness about the accuracy of orders and collections at the healthcare equipment company.

Senior nursing representatives were asked by the coroner to write her a letter outlining what changes have been made.

The coroner found that had the occupational therapist visited Mrs Rowe’s home after the bed was delivered, which was at the height of Covid at the time, “the error would have identified and corrected within a day”.

The inquest heard that the occupational therapist, who placed the bed order, believed Mrs Rowe had the correct mattress and “unfortunately the carers did not highlight the incorrect mattress was in place”.

The coroner also concluded that the delivery driver acted on his own initiative to take Mrs Rowe’s air mattress away when there was no request to do so.

Evidence heard from an expert witness was “persuasive” and the deep tissue injury and pressure sores were “directly connected” with the incorrect mattress after Mrs Rowe had no issues with the air mattress for seven months until she had a foam mattress.

Mrs Rowe, a "strong-minded and always immaculately dressed" 96-year-old widow, was a retired retail assistant and mother of eight who lived in Southend on Sea in Essex for most of her life until she moved to live closer to her son in Newtown who cared for her during the final 12 years of her life.

“It’s more important for me to get justice for her,” Keith Lowe said by way of explanation as to why he pushed for an inquest into how his mother died.

“A care company told me that it’s nice to see a family member actually taking it further. They informed me that there are a number of cases that are never taken forward.

“In my view there were a lot of mistakes being made. They are professionals and they should have picked up on the ulcers and maybe she wouldn’t have ended up in Shrewsbury [hospital]. At least I’ve tried to get the answers for mum.”