Phyllis Tromans

Executive Office of the Chair & Chief Executive 
Chair 
Chief Executive 
Executive Office  

: 
: 
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27th December 2024  

Mrs Louise Hunt  
HM Senior Coroner for Birmingham and Solihull  

By way of email only: 

Dear Mrs Hunt  

Inquest touching the death of Mrs Phyllis Tromans 
Response to Regulation 28 Report to prevent future deaths 

I  am  writing  in response  to the  Regulation  28  notice  issued following  the  conclusion  of the 
inquest  on  31  October  2024,  into  the  death  of  Mrs  Tromans  at  Queen  Elizabeth  Hospital 
Birmingham. 

We have carefully considered the concerns raised within your report to prevent future deaths 
and our response is set out below.  

1.It  is  likely  that  Mrs  Tromans'  tissue  damage  was  exacerbated  during  her  period  in  the 
Emergency Department. On admission, her Waterlow score indicated a high risk of pressure 
sores. That score was underestimated and the correct score would have indicated a very high 
risk.  She  spent  almost  18  hours  in  ED,  during  which  time  she  was  positioned  on  a  trolley 
without pressure area care. 

It is probable that Mrs Tromans' tissue damage accelerated during her prolonged stay in the 
Emergency Department. Her Waterlow score upon admission indicated a high risk of pressure 
sores, but the actual score should have indicated a very high risk i.e. the tissue substrate was 
poor.  She  was  positioned  on  a  trolley  for  nearly  18  hours  in  the  ED  without  adequate 
heightened levels of pressure area care, which likely contributed to the development of her 
pressure sores. 

In response to this, several measures are being taken to prevent future occurrences. Due to 
the increasing demand on the ED, which has led to patients spending longer than desirable 
periods  in  the  department,  the  Tissue  Viability  team  has  collaborated  with  ED  Matrons  to 
implement a project aimed at reducing pressure ulcers in the ED. This includes: 

•  Education: A targeted training program for ED staff covering topics such as pressure 
ulcer  categorization,  reporting  mechanisms,  skin  inspections,  and  repositioning 
techniques. 

•  Equipment: The introduction of new trolley mattresses with deeper pressure-relieving 
foam and the use of pillows to offload pressure from patients’ heels. This equipment is 
not conventionally used in ED but will now be available in this setting. 

 
 
 
 
 
 
  
      
  
  
 
 
 
 •  Documentation:  A  booklet  supporting  accurate  completion  of  Waterlow  scores  is 
being  updated  and  will  soon  be relaunched to  ensure  proper  documentation  across 
the Trust. 

Furthermore,  skin  champions  have  been  introduced  in  the  ED,  with  staff  undergoing 
comprehensive  training.  The  department  is  also  working  on  auditing  trolley  mattresses  to 
ensure  they  provide  effective  pressure  reduction,  with  plans  for  a  trolley  audit  program  in 
place. 

Assurance: The implementation of these measures will be monitored through regular audits 
of pressure ulcer data in the ED to assess effectiveness and identify areas requiring further 
intervention. 

2.Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute 
Medical  Unit  and  subsequently  to  ward  East  Ground  B.  This  required  repositioning  at  no 
greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions 
during her inpatient stay, the schedule was not adhered to. This led to occasions where Mrs 
Tromans was left in the same position for up to 14 hours.  

Mrs Tromans was admitted to the Acute Medical Unit (AMU) and subsequently to Ward East 
Ground B, where she had a repositioning schedule that required her to be repositioned every 
four  hours  to  prevent  pressure  sores.  However,  the  schedule  was  not  adhered  to  on  22 
occasions, resulting in her remaining in the same position for up to 14 hours, likely contributing 
to the deterioration of her condition. 

In response, several actions are being taken: 

•  Training:  In  December,  two  Tissue  Viability  Link  Worker  events  focused  on 
repositioning  were  held,  with  support  from  therapy  teams  using  pressure  mapping 
devices to identify pressure points and promote effective repositioning. The sessions 
also provided education on anatomy and physiology, with an emphasis on safe side-
lying techniques to relieve pressure. 

•  Compliance Monitoring: A weekly audit of repositioning practices in the AMU is now 
being  conducted,  with  real-time  feedback  provided  to  staff.  The  AMU  also  receives 
regular  communications  emphasizing  the  importance  of  following  the  repositioning 
schedule and completing daily care plans. 

•  Response Assessment Tool (RAT): The Tissue Viability team has implemented the 
RAT to scope trust-acquired pressure ulcer events. This tool, which will be used by 
senior  staff to  ensure repositioning  strategies  are  being  followed,  will  be  audited for 
compliance and quality. 

Assurance:  The  implementation  of  regular  audits  and  ongoing  educational  efforts  will  be 
monitored, with results reviewed in the spring of 2025 to assess improvements in repositioning 
practices and a reduction in pressure ulcer incidence. 

3.East  Ground  B  ward  had  a  paper  version  of  a  wound  care  plan  which  was  designed  to 
provide detailed monitoring of her skin condition and a treatment plan for pressure sore care. 
This was not completed at any stage.  

On Ward East Ground B, there was a paper-based wound care plan designed to monitor Mrs 
Tromans’ skin condition and provide a treatment plan for her pressure sores. However, this 
plan was not completed at any point during her stay, which hindered the timely and effective 
management of her pressure sores. 

 
 The Trust has responded by updating its wound care tools and processes: 

•  Updated  Wound  Assessment  Chart:  The  Wound  Assessment  Chart  has  been 
recently updated as part of the Wound Product Formulary review. This document is 
now available to staff, who are being trained in its use during patient reviews. The chart 
will be used to document skin assessments and treatment plans. 

•  Education and Training: The clinical educator for the Healthcare of Older Patients 
(HCOP)  service  is  delivering  additional  training  across  ward  areas,  with  senior  staff 
leading bi-monthly sessions to reinforce pressure ulcer prevention and care. 

Assurance:  The  use  of  the  updated  wound  assessment  chart  will  be  monitored  through 
patient assessments and quarterly audits to ensure proper documentation and adherence to 
care plans. 

4. The Matron's investigation into these gaps in care did not seek to establish why they had 
occurred.  This  raises  a  concern  about  the  quality  and  efficacy  of  the  Trust's  post-death 
investigations which in turn raises a concern for future deaths.  

The Matron's investigation into the gaps in care did not thoroughly explore why these failures 
occurred, which raises concerns about the effectiveness of post-death investigations within 
the  Trust.  A  more  comprehensive  investigation  would  involve  speaking  directly  with  staff 
involved in care delivery to understand the root causes of care failures. 

In  response  to  this,  the  leadership  team  has  reflected  on  the  investigation  process  and 
acknowledged the need for individual fact-finding interviews with staff involved in care delivery. 
Moving forward: 

• 

Improved Investigation Process: The investigation process will be revised to include 
individual  statements  from  staff  involved  in  care,  ensuring  that  all  aspects  of  care 
delivery are fully explored. These findings will be embedded into roundtable reports to 
provide greater assurance that all contributing factors are understood and addressed. 
•  Learning Dissemination: The findings from the investigation will be shared across all 
relevant clinical teams, with regular updates and action plans to ensure that lessons 
are learned and improvements are made. 

Assurance: The Trust will continue to focus on improving its investigation process to ensure 
that the causes of care gaps are thoroughly examined and that appropriate corrective actions 
are taken. Regular reports will be presented to senior leadership to track progress. 

Wider Learning and Improvement  

The issues identified in Mrs Tromans’ care have prompted widespread changes across the 
Emergency Medicine, Acute Medicine, and Healthcare of Older People (HCOP) services. The 
case has been shared at the QEHB Care Quality Meeting to disseminate learning, and actions 
are being reported through clinical delivery groups’ Quality and Safety meetings. Additionally, 
improvements in care delivery, monitoring compliance with standards, and preventing future 
incidents of pressure ulcers will continue to be a focus for ongoing staff education, audits, and 
process improvements across the Trust. 

These actions aim to enhance patient safety, improve pressure ulcer prevention, and ensure 
that staff are equipped with the necessary knowledge and resources to provide high-quality 
care. 

 
 I would like to assure you that the concerns raised within the Regulation 28 Report have been 
taken extremely seriously, which I hope is demonstrated in the steps that have been taken 
following Mrs Tromans’ death.   

Yours sincerely   

Chief Executive