Case review over Coventry woman's bed sores death
A 91-year-old Coventry woman died after being admitted to hospital with bed sores, which she got while being cared for at home.
A serious case review into events leading up to the woman's death found she had four serious ulcers on her body when admitted to hospital.
Her cause of death was given as sepsis, also known as blood poisoning.
The city council said it stopped using an agency involved in her care soon after reviewing the case.
The woman, who has not been identified, had been in hospital after a fall but allowed home for care, receiving four visits a day from an un-named care agency.
She died the day after being admitted back into hospital, in January 2009.
The case review concluded better communication between health and social care workers would have improved her care and her deterioration would have been noticed and addressed more quickly.
The review also found that supervision of the care agency looking after her should have been more "active and dynamic".
Following the report the city council said it was renewing its commitment to protect vulnerable adults.
Brian Walsh, chairman for Coventry's Safeguarding Adults' board, said he considered reducing the likelihood of this happening to anyone again to be the most important outcome of the review.
The council also said police and the Crown Prosecution Service had investigated the case but had taken a decision not to prosecute.