Carol Divall

Rachel Redman 
Assistant Coroner for East Sussex 
Innovation Centre 
Highfield Drive 
St. Leonards-on-Sea 
East Sussex 
TN38 9UH 

8th July 2024 

Dear Ms Redman, 

East Sussex Healthcare Trust Response to Regulation 28 Report – Carol Ann Divall 

Thank  you  for  your  letter  of  14th  May  2024,  enclosing  your  formal  report  under  Regulation  28  to 
Prevent Future Deaths you made at the conclusion of the Inquest into Mrs Carol Ann Divall’s death 
on  29th  October  2022  (Inquest  concluded  on  26th  April  2024).  I  would  like  to  convey  my  sincere 
condolences to Mrs Divall’s family following her death and would like to assure them that we have 
considered  all  the  recommendations  in  the  report  and  have  made  changes  to  our  systems  as  a 
result. 

The  Prevention  of  Future  Deaths  report  identifies  the  following  areas  of  concern,  and  we  address 
each one in turn with our findings and actions that we have undertaken, or plan to undertake. 

A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and
drink  and  take her oral medication. She was referred to the dietitians on 2.10.22 and
triaged  by  an  Assistant  the  following  day.  She  was  not  prescribed  Fortisip  until
14.10.22  by  which  time  she  was  becoming  malnourished.  The  oral  thrush  continued
until  discharge.  Nystatin  appeared  to  be  prescribed  once  on  12.10.22  and  was  not
prescribed on  discharge  nor  mentioned in the  discharge  summary.  I  heard  evidence
on  PFD  matters  that  software  which  requires  a  clinician  to  check  oral  care  is  being
implemented. I remain of the opinion that this forms part of basic nursing care which
was overlooked in Mrs Divall's case.

We recognise that the mouthcare received by Mrs Divall was not of a standard we expect. 
Since  2022  the  Malnutrition  Universal  Screening  Tool  (MUST)  and  Mouthcare  assessment 
have been a central element of basic documentation. At the end of last year both documents 
were  transferred  to  an  electronic  system,  to  enable  staff  to  record  and  monitor  the  care 
provided to patients, with a decreased risk of losing manual recording.  

High risk patients  now receive daily mouthcare reviews, medium risk patients are reviewed 
every  other  day,  and  low  risk  patients  are  reviewed  every  third  day  ensuring  that  any  oral 
concerns  are  picked  up  in  a  timely  manner  and  managed  until  improvement  is  seen.  All 
reviews are prompted on the electronic system and highlighted if not actioned.  

We  have  developed  regular  senior  nurse-led  audits  to  measure  the  quality  of  compliance 
with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality 
MUST assessments, including evidence of treatments commenced.   

 The  Trust  has  now  established  a role  (the  ‘Mouth  Care  Matters’  Lead)  that  is  dedicated  to 
the promotion of good standards of mouthcare for patients and targeted training is delivered 
as per requirements and individual patient need (for example, in the event of a patient who is 
distressed  or  failing  to  comply,  additional  support  and  training  would  be  available  to  staff 
providing care).  

We have revised the Planning Care Together Policy Respecting Patient Choice with Advised 
Treatment  policy,  which  provides  staff  with  guidance  to  manage  discussions  with  patients 
when  agreeing  an  appropriate  treatment,  and/or  intervention.  It  encourages  family,  carers, 
and  advocates  to  be  involved  in  planning  care.  This  is  especially  relevant  if  and  when 
patients are unable to fully cooperate and/or are very resistant to receiving care, where there 
are  concerns  about  capacity  or  impaired  cognitive  function.  This  policy  is  on  the  Trust 
extranet for all staff to access and it is referred to in training for  mental health capacity and 
has been introduced to the Mouthcare training sessions with immediate effect.  

Turning  to  the  prescription  of  Fortisip,  this  is  typically  undertaken  following  a  registered 
dietitian’s assessment. We accept that doctors could have prescribed this prior to review by 
a  dietitian  in  this  case.  On  this  occasion  due  to  a  coding  error  at  the  point  of  triage,  the 
urgency of our response is not as it should have been. Dietetic Assistant (DA) competencies 
have now been updated and additional training and support are given to DAs regarding the 
importance  of  coding  correctly  at  this  point  in  the  pathway,  to  minimise  the  potential  for 
recurrence of this error.  

Following the completion of the MUST or mouthcare assessment on admission, the dietitians 
will have base line information to work from to enable a full assessment of the patient. Any 
concerns are highlighted to dietitians via the referral process and  from communication with 
the  MDT,  patient  and  family.  As  part  of  the  learning  implemented  following  Mrs  Divall’s 
experience, all ward staff have received escalated communications to remind them that they 
can offer nourishing drinks such as Complan shakes and thickened yoghurts prior to dietitian 
referral or review, as long as there are no concerns about swallowing difficulties/dysphagia. 
The Dietetic team additionally promote the availability of high calorie, high protein options on 
the wards to staff and patients. 

We accept that the medical records show the prescription of Nystatin was not continued onto 
the  next  weekly  paper  medication  chart  when  the  previous  one  was  full.  We  have  recently 
introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk 
of a medication being missed is far reduced as the medication will stay on the system until 
the  course  is  finished  or  stopped.  We  anticipate  undertaking  an  audit  of  the  new  EPMA 
system within this financial year to review the impact on missed medication. 

B. Mrs Divall was referred to the Physiotherapy Department 2 weeks after admission but
was rarely assisted with mobilisation and left to sit out in her chair for long periods.
Action should have been taken to encourage Mrs Divall to mobilise more often in an
attempt to rehabilitate her after her surgery.

We recognise that further actions could have been taken to encourage Mrs Divall to mobilise 
more often to rehabilitate her after her surgery, noting the inherent risk of trying to mobilise a 
person if they do not wish to cooperate for any reason. Having reviewed the documentation, 
the Physiotherapy and Therapy Assisted Discharge Service (TADS) team visited Mrs Divall 
on 19 occasions during her time with us and she was able to actively participate to varying 
degrees in 15 of these sessions. 

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 When  Mrs  Divall  was  an  in-patient,  we  did  not  have  a  routine  Physiotherapy  weekend 
service and had experienced staff sickness as well. We have now made changes to the rota 
for this service and since mid-May we now have a Saturday service for new assessments of 
patients who have sustained a fractured Neck of Femur.  

We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) 
in the period since this incident. 

C. Mrs  Divall  developed  a  grade  4  sacral  pressure  sore.  She  was  not  referred  to  the
Tissue Viability Nurse (TVN) until 1.10.22 who confirmed in her evidence that it would
have taken 12-14 days to develop and would therefore have been available to be seen
by  the  nursing  staff  caring  for  her.  Contributing  to  the  deterioration  of  her  pressure
sore  was  the  deflating  of  her  hybrid  mattress  on  at  least  2  occasions.  Mr  Divall
noticed  who  visited  for  long  periods  every  day  noticed  that  his  wife  was  never
repositioned as she should have been on a 2 hourly basis at any time during his daily
visits. I  consider that Mrs  Divall's immobility  and malnourishment contributed  to  the
development of her pressure sore the care of and severity were not mentioned in the
discharge summary.

We  acknowledge  the  unacceptable  delay  in  dealing  with  the  pressure  sore.  We  note  that 
category  2  pressure  damage  was  first  documented  in  Mrs  Divall’s  health  records  on  20 
September 2022, ten days before the referral to the TVN.  

In order to strengthen the approach regarding managing pressure sores, the Tissue Viability 
Team are supporting the ward to undertake a quality improvement (QI) project in relation to 
the prevention and management of pressure ulcers including the recognition of potential skin 
damage  likely  to  deteriorate.  This  is  especially  relevant  to  patients  who  have  a  history  of 
trauma which often incorporates frailty, poor health and a long lie prior to their admission to 
the ward. The success of the interventions on this QI project to reduce pressure ulcers in the 
unit will be reviewed and recommendations extended across the organisation in all wards.  

We also acknowledge that the communication and handover on discharge to the community 
nursing  teams  and  with  Mr  Divall  in  relation  to  the  extent  of  the  wound  and  treatment 
required for the pressure damage was inadequate.  

The  Chief  Nurse  has  proposed  a  new  process  called  the  ‘5P  Process  for  Discharge’  to 
improve the  communication  related  to  significant  pressure  damage  on  discharge.  This  has 
been  presented  and  discussed  at  length  with  senior  nurses  across  the  organisation  and  is 
currently  being  developed  and  implemented.  The  process  includes  utilising  our  medical 
illustration team to take clear images of wounds for sharing with care partners with consent 
as required. We have included a copy of the process as Attachment A, and a copy of the 5P 
slide deck at Attachment B. 

We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we 
would anticipate that the mattress provides sufficient protection to patients at risk of pressure 
damage, however we note this did not happen in this case. We recently completed a Trust-
wide  audit  of  all  inpatient  beds  to  understand  the  current  picture  and  are  considering  the 
findings in order to ensure effective next steps. 

Additionally, as part of the QI project  noted above, Benson Ward and Egerton Trauma Unit 
now  complete  daily  checks  on  all  hybrid  mattress  pumps  and  this  is  documented  on  a 
checklist  (Attachment  C).  Actions  are  taken  to  supply  pumps  to  those  patients  that  need 
them (as all mattresses are hybrid) and address any issues with teams on the ward, who are 

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 supported  by  ‘trouble-shooting’  sheets  (see  attachment  D).  It  is  our  intention  to  take 
learnings from these pilot areas and share across the Trust. 

D. The Discharge Summary was misleading to the District Nurses who were unaware of
the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did
not make clear that Mrs Divall had been discharged for end of life care.

It  is  acknowledged  there  was  no  mention  of  the  pressure  damage  within  the  Doctor’s 
discharge letter. Although the District Nurse referral did state there was a pressure ulcer and 
the  category,  it  is  also  acknowledged  that  it  should  have  been  more  detailed  to  include  a 
range of factors, including; the reason for admission/procedure, what is required from District 
Nurses,  size,  location,  appearance  (slough/black),  treatment  actions,  dressing  plan,  when 
this  should  be  started,  how  often,  and  other  measures  such  compliance,  aids  used,  air 
mattress and care needs. 

To address these information concerns, we have developed a flow chart on how to refer to 
District  Nurses  and  what  information  needs  to  be  shared  to  support  decision  making  and 
tasks related to fast track discharge, available on the extranet and in the discharge policy.  

With regard to concerns around End-of-Life Care (EOL), from our documentation it was not 
recognised  that  Mrs  Divall  was  EOL,  and  she  was  therefore  not  referred  to  the  Specialist 
Palliative  Care  Team  and  this  was  not  described  on  her  discharge  documentation.  As  a 
result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention 
is to share this throughout our hospitals, see Attachment E. 

The  flowchart  prompts  the  recognition  of  factors  such  as  frailty  score,  Nottingham  Hip 
Fracture Score (30 day mortality), ongoing Orthogeriatrician input and several other details 
to be kept under review and monitored. On consideration of this, should a patient show signs 
of  increased  frailty  or  mortality,  or  decreased  nutrition  or  rehabilitation,  this  will  trigger 
immediate discussion with family and next of kin, a Multidisciplinary Team Discussion, and a 
best interests meeting. The discussions will support in identifying if a patient is either EOL or 
limited  life  expectancy  (less  than  24  months)  so  that  we  may  refer  them  to  a 
suitable/appropriate pathway consistent with their care needs.  

Patients  identified  as  limited  life  expectancy  will  receive  input  from  the  Frailty  Team,  and 
discussions  with  family  to  consider  the  most  appropriate  pathway  such  as  fast-track  for 
home support  or  involving  the  care  home  and other care  agencies where appropriate.  The 
EOL pathway will involve Palliative Care input and discussions with family regarding where 
the patient will spend their last days of life, including home support, nursing home, hospice 
or hospital environment.   

E. The  RCA  was  insufficient  and  did  not  address  all  of  the  issues  surrounding  Mrs

Divall's care nor did it properly address those issues it did consider.

The  report  in  question  was  a  specific  Pressure  Ulcer  Root  Cause Analysis  report  and  we 
accept  that  other  issues  and  concerns  in  the  care  were  not  addressed  as  they  were  not 
noted as concerns at that time during Mrs Divall’s admission.   

Under  the  NHS  England’s  Patient  Safety  Incident  Response  Framework  (PSIRF)  the Trust 
have  developed  a  Pressure  Ulcer After Action  Review  (AAR)  template  in  collaboration  with 
the  TVN's  and the  Pressure  Ulcer  Review  Group  (PURG)  –  see Attachment  F.  The  aim  of 
PSIRF is to apply a broader approach to addressing patient safety issues, such as pressure 
ulcers, taking the focus away from investigation and individual incidents to instead focus on 

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 quality improvement. The template has been trialled and on review is being used effectively, 
especially  around  learning  and  recommendations,  it  is  an  opportunity  to  review  the  care 
holistically and the look at the whole journey of the patient.  

By  applying  this  approach  to  the  care  delivered  to  Mrs  Divall  the  Trust  acknowledge  and 
accept  the  concerns  of  the  Coroner.  We  are  aware  we  need  to  review  and  improve  our 
communication  with  next  of  kin  and,  as  above,  between  teams  on  discharge  such  as  the 
District  Nurses  and  ward  to  ensure  important  information  is  cascaded  avoiding  confusion 
and  distress  to  families.  We  now  have  bimonthly  Quality  Summits  which  all  the  Ward 
Matrons will be attending in person to emphasise the importance of communication between 
families but also between staff in order to ensure that care provided is of the highest quality. 
We have also developed quality documentation audits and discharge checklist audits so that 
where we see a miscommunication we can put it right in the moment. 

We recognise the need for a rapid escalation process that enables us to recognise very high 
risk/complex  patients  who  may  be  resistant  to  care,  which  would  have  triggered  a  ‘best 
interests’  meeting  and/or  multidisciplinary  meetings  in  real  time  to  address  the  issues  staff 
were  experiencing  in  trying  to  deliver  care.  All  of  this  should  have  been  shared  and 
discussed  with  her  Next  of  Kin  so  they  were  aware  and  understood  the  extent  of  this  and 
also  the  impact/risk(s)  it  posed.  The  Trust  has  developed  a  Standard Operating  Procedure 
that 
(SOP),  currently  being  approved 
will  systematise  the  approach  for  teams  who  are  caring  for  patients  to  whom  this  SOP 
applies. 

through  our  clinical  governance  process 

I  hope  this  letter  provides  you  and  Mrs  Divall’s  family  with  assurance  that  we  have  taken  the 
learning  extremely  seriously  and  have  made  significant  improvements.  Once  again,  my  sincere 
condolences to Mrs Divall’s family. 

Yours sincerely, 

Chief Executive 

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