Myra Maxfield

Emma Serrano 
Stoke-on-Trent and North Staffordshire  
Coroner’s Chambers 
547 Hartshill Road 
Hartshill  
Stoke-on-Trent  
ST4 6HF 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

11 December 2023  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Myra Maxfield who died on 
12 March 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  25 
October 2023 concerning the death of Myra Maxfield on 12 March 2022. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Myra’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the coroner that the concerns raised about  Myra’s care have 
been listened to and reflected upon.  

NHS England sets out our response to each of your concerns below.  

1.  Evidence emerged during the inquest that it was crucial that patients who 
were  at  risk  of  developing  pressure  ulcers,  had  ulcers  already,  or  had 
developed them whilst in hospital, saw the Tissue Viability Team as soon as 
possible, and usually within 6 hours. 

People  who  are  bedbound  are  at  increased  risk  of  pressure  ulcers.  Healthcare 
professionals play a crucial role in identifying individuals who are at risk of developing 
pressure ulcers (using a valid and reliable risk assessment tool, as per the National 
Institute of Clinical Excellence (NICE) guidance below) to identify their level of risk and 
inform the development of an individualised plan of care.  

People  admitted  to  hospital,  or  a  care  home  should  have  their  risk  of  developing  a 
pressure  ulcer  assessed  by  a  healthcare  professional  within  six hours  of  being 
admitted. 

The National Institute of Clinical Excellence (NICE) guidance CG179 Pressure Ulcers: 
Prevention and Management, published April 2014, recommends that adults who have 
been assessed as being at high risk of developing a pressure ulcer are encouraged to 
change their position frequently and at least every four hours.  

If they are unable to reposition themselves, assistance should be offered to enable 
them to do so, using appropriate equipment if required, documenting the frequency of 
repositioning required. In cases where a patient develops a pressure ulcer, healthcare 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 professionals should regularly measure and assess its depth and severity to determine 
the appropriate level of care and treatment.  

The recently published National Wound Care Strategy Programme (NWCSP) Clinical 
Recommendations,  align  with  the  Quality  Standard  from  NICE  and    emphasise  the 
need  for  assessing  patient  risk  of  pressure  ulcers  within  six  hours  of  hospital 
admission.  The  NWCSP  was  launched  with  the  purpose  to  improve  the  quality  of 
chronic wound care  by  developing recommendations for  preventing,  assessing  and 
treating people with wounds to optimise healing and minimise the burden of wounds 
for patients, carers and health care providers.  

There  are  no  specific  guidelines  for  when  patients  should  be  referred  to  a  Tissue 
Viability Specialist (TVS) within the NICE guidance or in the international best practice 
guidelines. You may wish to engage with NICE or the NWCSP regarding this issue.  

2. 

It  was  said  that  delays  in  doing  so,  could  be  causative  in  the  death  of 
patients. 

Every organisation has a policy for preventing and managing pressure ulcers, which 
staff should adhere to, and should align with NICE guidance and best evidence-based 
practice.   

In the case of a patient showing signs of a severe infection that could potentially lead 
to death, it is expected that the patient would be promptly referred to the medical team 
for urgent review, treatment and appropriate intervention and management.  

Even if the patient was seen by the TVS (Tissue Viability Specialist) urgently, it is likely 
that their first course of action would be to refer the patient to the medical team for 
review and appropriate management and treatment.  

3.  Evidence  emerged  that  at  the  Royal  Stoke  University  Hospital,  Tissue 
Viability  is  not  available  over  the  weekend,  and  this  leads  to  substantial 
delay in patients being seen. 

Tissue Viability Teams across England differ in size, aligned to provider requirements 
with only a few providing a service seven days a week. Typically, most TVS services 
prioritise  their  referrals  on  Monday  mornings  to  ensure  prompt  attention  to  urgent 
cases to enable them to be seen. Management and care plans are documented for 
the ongoing treatment and management of the patient by ward / clinical staff caring 
directly for the patient.  

NHS  England  is  not  able  to  provide  comment  on  the  provision  of  the  service 
specifically within Royal Stoke University Hospital and would refer you to the Trust on 
this issue.  

I would like to assure you that further work has been progressed nationally to further 
improve pressure ulcer care and reduce the risk of harm to patients. In addition to the 
NWCSP, further work is also underway as part of the National Patient Safety Strategy 
and further work is underway to progress a diagnostic phase of improvement work in 
relation to pressure ulcer prevention and management. 

 
 
 
 I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Executive Suite 
Trust Headquarters 
Springfield 
City General Site 
Newcastle Road 
Stoke on Trent 
ST4 6QG 

12 December 2023 

STRICTLY PRIVATE & CONFIDENTIAL 
Mrs Emma Serrano  
H M Area Coroner  
Stoke on Trent and North Staffordshire 

Dear Mrs Serrano  

Mrs Myra MAXFIELD 

Further to your letter dated 25 October 2023, I am pleased to provide a response under paragraph 7 of 
Schedule  5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, addressing your concerns surrounding the death of Myra Maxfield.  

Recorded Circumstances of the Death 
On the 1st April 2022, you commenced an investigation into the death of Myra Maxfield. 

The investigation concluded at the end of the inquest on 15th September 2023. The conclusion of the 
inquest was a short narrative conclusion of: Complications following a fall on a background of natural 
causes. 

The cause of death was: 

1a)   Upper gastrointestinal bleed 
1b)  
1c)  
II)  

Infected pressure ulcer following hip arthroplasty 
Fall 
Frailty of old age 

Concerns 
During the course of the inquest you felt that evidence revealed matters giving rise for concern. In your 
opinion, matters for concern are as follows: 

1.  Evidence emerged during the inquest that it was crucial that patients who were at risk of developing 
pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability 
Team as soon as possible, and usually within 6 hours. 

2.  It was said that delays in doing so could be causative in the death of patients. 

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 3.  Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over 

the weekend and this leads to substantial delays in patients being seen. 

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  

In your opinion, action should be taken to prevent future deaths.  

Response: 

1.  As a point of clarification on the issues that you have raised in Point 1 of your letter, regarding the 
fact  that  ‘it  was  crucial  that  patients  who  were  at  risk  of  developing  pressure  ulcers,  had  ulcers 
already,  or  had  developed  them  whilst  in  hospital,  saw  the  Tissue  Viability  Team  as  soon  as 
possible, and usually within 6 hours’.  

The  NICE  Pressure  Ulcer  Quality  Standard  (QS89),  dated  2015:  Pressure  Ulcer  Risk  Assessment  in 
Hospitals  and  Care  Homes  with  Nursing,  states  that  people  admitted  to  a  hospital  or  care  home  (with 
nursing) have a pressure ulcer risk assessment within 6 hours of admission. This is an important point of 
clarity,  which  differs  from  your  statement  that  patients  should  be  seen  by  the  Specialist  Tissue  Viability 
Team within 6 hours of admission. 

At  UHNM,  like  other  acute  Trusts,  The  Pressure  Ulcer  Risk  Assessment  is  completed  by  the  admitting 
Ward/Department Registered Nurse within 6 hours of admission and 6 hours of transfer to another inpatient 
area. This is reflected in UHNM Trust Policy C63, Prevention and Management of Pressure Ulcers.  

2.  Delays may be causative in the death of patients. 

Although,  it  is  deemed  best  practice to  complete  the  Pressure  Ulcer  Risk  Assessment  within  6  hours  of 
admission/transfer  a  delay  in  completing the  initial  assessment  may  not  necessarily  be  causative  in  the 
death of patients, as stated in Point 2 of your letter as the patient’s outcome would very much depend upon 
the standard of care delivered thereafter. It is current practice at UHNM to consider all patients admitted to 
the  Emergency  Department  as  being  high  risk  of  developing  pressure  ulcers  so  that  optimal  mitigating 
interventions are delivered in a timely manner.  

Referral  criteria  for  Ward/Department  Teams  to  refer  patients  to  the  Tissue  Viability  Team  for  specialist 
advice and support is available on the UHNM Trust Intranet pages. 

3.  Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over 

the weekend and this leads to substantial delays in patients being seen. 

Mrs Maxfield was admitted to UHNM at 14:15 hrs on Friday 3rd December 2021 with an existing Category 
4 Pressure Ulcer, to the spinal area, which already had a dressing in place. In the evidence presented in 
court it was acknowledged that there was a delay in the initial Pressure Ulcer Risk Assessment, which was 
assessed and documented within 11 hours of admission (as opposed to 6 hours). This was due to high 
staffing acuity and clinical demand during the Covid-19 Pandemic, where direct patient care was prioritised 
over documentation. However, it should be noted that the Pressure Ulcer was already present and had a 
dressing  in  situ  during  this  time.  An  incident  report  was  completed  (ID:259932),  clinical  photography 
requested and a safeguarding referral was made within the Department, which is deemed good practice. 

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 The Spinal Team reviewed Mrs Maxfield and requested an MRI scan to rule out osteomyelitis and promptly 
commenced intravenous antibiotics.  

Mrs  Maxfield  was  referred  to  the  Specialist  Tissue  Viability  Team  for  advice  about  management  of  the 
existing Category 4 Pressure Ulcer on Saturday 4th December 2021 and subsequently reviewed on the next 
day, Sunday 5th December 2021. Ordinarily, a Category 4 Pressure Ulcer identified on admission would be 
reviewed  by  the  Tissue  Viability  Team  within  1-3  working  days  and  on  this  occasion  Mrs  Maxfield  was 
reviewed within 1 working day as the team were on site during that particular weekend, due to extenuating 
circumstances  within  the  Trust.  In  addition,  Mrs  Maxfield  was  reviewed  and  followed  up  by  the  Tissue 
Viability Team on 14th December 2021 and 23rd December 2021 prior to her discharge on 23rd December 
2021. 

We strive to provide a high standard of care to all of our patients and preventing avoidable pressure ulcers 
and managing existing pressure ulcers, as in the case of Mrs Maxfield, is an important quality metric. People 
in hospital can be at higher risk of pressure ulcer damage but we have a range of support for teams to 
minimise the risk of pressure ulcer development or deterioration. UHNM provide a regular 5-Day (Monday 
–  Friday)  Tissue  Viability  Service,  which  is  in  line  with  most  acute  Trusts  nationally.  However,  as 
demonstrated  in  the  case  of  Mrs  Maxwell,  a  limited  service  is  provided  at  weekends  in  extenuating 
circumstances on an ad hoc basis. As presented to your court by 
 Lead Clinical Nurse Specialist 
for Tissue Viability and Continence, the risk of not providing a routine Tissue Viability Service at weekends 
is mitigated by having pathways, policies and guidance to support frontline clinicians with pressure ulcer 
prevention and management of existing pressure ulcers out of hours. Training in all aspects of pressure 
ulcer prevention and ongoing management is provided to Ward/Departmental staff. 

In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment 
completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also 
ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team 
for  specialist  advice  and  support  is  reviewed  and  included  in  UHNM  Trust  Policy  C63,  Prevention  and 
Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the 
severity of the Pressure Ulcer, by our Specialist Tissue Viability Team. 

I do hope that the above information provides assurance that the Trust has taken the concerns raised at 
the inquest seriously. 

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. 

Yours sincerely 

CHIEF EXECUTIVE 

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