On the 4th of February 2025, I commenced an investigation into the death of Ronald Colin Nelson. The investigation concluded at the end of the inquest on the 15th of January 2026

A narrative conclusion was given.

Colin died from aspiration pneumonia which was caused by his advanced dementia. His advanced dementia led him to be non-verbal. He became bed bound on the 17th of October 2024 due to a respiratory infection and developed pressure sores as a consequence of this. He was treated for grade 2 pressure sores whilst in hospital and when discharged to his care home this deteriorated to a grade 3 and then a grade 4 causing sacral osteomyelitis. There were significant gaps in Colin’s records at the care home and evidence a care plan was not followed leading to the deterioration of the pressure sores and the following infection which led to his final admission to hospital. He was admitted to Hospital on the 16th of December 2024 for the final time with suspected sepsis. He was diagnosed with aspiration pneumonia on background of advanced dementia. Colin’s pressure sores had deteriorated to category 4 and sacral osteomyelitis was identified on scans. He had very little reserve to fight such infection by this time and died on the 26th of January 2025 at the Queens Medical Centre, Nottingham. It is my view that a care plan was not complied with and the records from the care home were vague and at times misleading.