Susan was a resident in a care home who develo-ped pressure ulcers. She was under the care of District Nurses, who asked a GP and the tissue viability team for input, but they were shown out-of-date photographs and didn't appreciate the extent of her deterioration. As a result Susan wasn't precribed antibiotics when she should have been. She deteriorated rapidly and was admitted to hospital, where she died two months later.

The DNs also failed to share information with the care team or Susan's family.