Rachael Ryan

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

: 
: 
: 

2nd January 2025  

Mr Brenchley 
Assistant Coroner for Birmingham & Solihull  

By way of email only: 

Dear Mr Brenchley 

Inquest touching the death of Rachael Alicia Elizabeth Ryan 
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 5 November 2024, into the death of Miss Ryan on 21 June 2024 at Birmingham 
Heartlands Hospital.   

We have carefully considered the concerns raised within your report to prevent future deaths 
and our response is set out below. Whilst the concerns raised relate to care at Birmingham 
Heartlands Hospital, the  actions  arising  from this  and  the  wider  case  review  will  be  shared 
across UHB (referred to as ‘the Trust’). 

On 23 April Miss Ryan’s treating consultant geriatrician received advice from the infectious 
diseases  team  that  a  deep  tissue  biopsy  was  strongly  recommended  to  best  guide  the 
antibiotic therapy for her infection.  

Despite him liaising with the Tissue Viability Nurse service, the Trauma and Orthopaedic team 
and  the  Plastic  Surgery  team  (based  at  the  Queen  Elizabeth  Hospital)  between  23rd  April 
2024  and  1st  May  2024,  none  of  these  teams  could,  for  different  reasons,  facilitate  this 
procedure.  As  a result,  it  was  not  until 2nd May 2024  that  assistance  was  sought  from the 
interventional radiology team who agreed to help.  

The procedure was initially due to take place on 7th May but had to be postponed due to Miss 
Ryan  being  on  warfarin  and  there  were  then  further  delays  due  to  non-availability  of  the 
relevant specialist as well as the need to stop her existing antibiotics for 24 to 48 hours before 
the procedure. The procedure was finally carried out on 21st May 2024. 

On 22nd May 2024, a new antibiotic regimen was commenced with it being noted that one of 
the bacterial organisms identified from the biopsy, namely Morganella morganii, was resistant 
to co-amoxiclav, the antibiotic which Miss Ryan had most recently been receiving from 15th 
April until 19th May.  

 
 
 
 
 
 
 
 
 
  
     
   
 
 
 
 
 
 
  
 
 
 
 
 Although I heard evidence that the delay in starting the new antibiotic regime was unlikely to 
have altered the sad outcome in this case in part due to Miss Ryan’s existing frailty and poor 
prognosis, I am concerned that in the absence of any existing protocol regarding the correct 
specialism for the biopsy procedure, no Multi-disciplinary meeting bringing together specialists 
from the different disciplines was offered or held in this case to agree the best way forward. 
This led to a delay and a lack of collaboration between teams which could, if repeated, result 
in an avoidable death.  

In response to this, the Trust has undertaken a number of actions to determine what measures 
need to be taken in order to prevent an avoidable death from the issues outlined.  

•  A  multidisciplinary  learning  response (round table)  was  conducted  on  18  December 
2024  to  review  all  aspects  of  Miss  Ryan’s  care  at  UHB  during  her  admission, 
incorporating the Regulation 28 notice issued.   

•  The existing  relevant  Trust  guidelines  (CG-1164:  Surgical Management of  Pressure 
Sores and CG-195: Guidelines for Pressure Ulcer Prevention and Management) were 
reviewed as part of the above. 

•  Correspondence  has  also  been  received  from  the  Clinical  Delivery  Group  lead 
encompassing Interventional Radiology which has been incorporated into the planned 
actions.  

•  The  Medical  Director  and  Lead  Nurse  for  Tissue  Viability  retrospectively  reviewed 
learning from Trust cases of pressure ulcers complicated by osteomyelitis to ensure 
this was captured to inform the required measures. 

Through this process, the root causes of the issues outlined within the coronial review plus 
other factors which influenced the delay in performing of the deep tissue biopsy were identified 
to inform the measures to be undertaken.  These were: 

•  Lack of clarity from the parent ward team as to the goal of treatment of Miss Ryan’s 
deep pressure ulcers and subsequent small focus of osteomyelitis. In circumstances 
such as this in frail patients when offloading of the pressure areas and debridement 
cannot  be  performed,  and  soiling  is  unavoidable,  there  is  a  high  risk  of  failure  with 
antibiotics  regardless  of  microbiologically-targeted  therapy  and  suppression  or 
palliation would be appropriate.  

•  The majority of the infection service reviews were carried out remotely without seeing 

Miss Ryan and not as part of an MDT, contributing to this lack of clarity.  

•  Without a clear goal of treatment, it was harder for the parent ward team to be clear 
whether  orthoplastics  should  be  contacted  as  per  CG-1164,  or  musculoskeletal 
radiology  as  per  CG-195.  It  was  agreed  that  Interventional  Radiology  were  the 
specialty  to  be  contacted  to  undertake  deep  tissue  biopsies  in  cases  such  as  Miss 
Ryan’s. The guidance however within CG-195 was not felt to be specific enough and 
referred to MSK Radiology rather than Interventional Radiology.  

•  The terms ‘sharp debridement’ and ‘deep tissue biopsy’ were used interchangeably by 
the requesting parent team, leading to a lack of clarity from the specialist teams as to 
what was actually being requested.   

By way of assurance on measures to address the concerns raised by the coronial process 
and incorporating the factors above, the following has taken place: 

•  There has been a refreshing of consistent medical leadership on ward 30, which had 
been  dependent  on  locum  senior  medical  staffing.    Ward  staff,  including  the  Ward 
Manager  present  at  the  Round  Table  on  18  December  2024,  reported  that 
multidisciplinary working had improved considerably since this measure in November 
2024, with improvement in goal-setting for treatment and care plans.  

 
 
 
 
 
 •  The  pathway  and  means  of  contacting  Interventional  Radiology  for  deep  tissue 

biopsies has been clarified by the department.  

•  The  Infection  Service  will  reiterate  via  their  Morbidity  and  Mortality  meeting  that  in 
cases of complex pressure ulcers, a bedside review of the patient should take place to 
obtain a holistic view of the most appropriate goal of treatment and form part of  the 
multidisciplinary  meeting  with  the  ward  team  and  Tissue  Viability.  Those  cases 
involving osteomyelitis where the appropriate goal is cure rather than suppression will 
be taken by the Infection Service to the complex bone MDT of which they are a core 
member.  

•  Appendiceal  guidance  to  supplement the  existing  Trust  guidelines  will  be written  by 
the Infection  Service,  Healthcare  of Older  Adults,  Tissue  Viability  and  Interventional 
Radiology. A draft should be complete by February 2025. This will include the following 
points: 

1.  A decision-making aid to determine goals of treatment for complex pressure ulcers 
2.  How and when to contact the Infection Service and what can be expected from them 
3.  The process of requesting a deep tissue biopsy via Interventional Radiology and who 

to contact to discuss and vet the request 

4.  Clarification of the difference between sharp debridement and deep tissue biopsy 

This supplementary guidance will be launched via a Lesson of the Month safety notice. 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 
Miss Ryan’s death.   

Yours sincerely   

Chief Executive