Sheila Wexler

Mr Ian Potter  
HM Assistant Coroner 
Coroner area of Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London  
N1C 4PP  

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

17 March 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Sheila Josephine Wexler 
who died on 17 February 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  15 
January 2025 concerning the death of Sheila Josephine Wexler on 17 February 2024. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Sheila’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Sheila’s care 
have been listened to and reflected upon.   

Your Report raised concerns over the risks posed by NHS use of NRS Healthcare for 
the  provision  of  important  healthcare  equipment.  Colleagues  from  NHS  England’s 
Medical  Devices  and  NHS  Supply  Chain  teams  and  London  region  have  reviewed 
your Report and aided my response to the Coroner.  

NRS  Healthcare  are  listed  on  the  NHS  Supply  Chain  Framework  for  Aids  of  Daily 
Living,  for  the  supply  of  basic  living  aids  with  no  service  or  maintenance  provision 
included  in  the  Framework.  The  Framework  does  not  include  the  provision  of  the 
lateral turning system. The contract for services described in your Report has not been 
contracted  through  NHS  England’s  NHS  Supply  Chain  team  and  our  national 
Framework, but through the London Community Equipment Consortium, a consortium 
of 21 London boroughs/local authorities (LAs), in a contract awarded by the Cabinet 
Member for Adult Social Care, Public Health and the Voluntary Sector running from 1 
April 2023 to 31 March 2028. The Coroner may therefore wish to refer your concerns 
to the Department of Health and Social Care (DHSC) or the London Consortium.   

However, my regional London colleagues, together with the London Consortium, The 
Royal Borough of Kensington & Chelsea Council, and Westminster City Council have 
provided the below information.  

Background 

Following  a  successful  procurement  process,  NRS  Healthcare  was  awarded  the 
equipment contract for the London Community Equipment Consortium in September 
2023, supplying 21 of London’s local authorities and associated acute, community and 
mental health providers. 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 There was a short mobilisation period for the new contract due to challenges with the 
transition  process  reducing  the  preparatory  period  to  three  months,  with  a 
consequential  impact  on  staffing,  loss  of  access  to  depot  sites  and  the  unfortunate 
lack of availability of any historical service level data during the transition. 

This  was  further  compounded  by  a  cyber-attack  affecting  operations  of  NRS 
Healthcare and other community equipment services nationally over Easter weekend 
in 2024. NRS Healthcare was able to quickly establish a manual operation, but it took 
up to six weeks for them to recover full online systems and only in August 2024 was 
the backlog of cases and data gaps completed. 

Regional involvement 

Following completion of the transition to NRS Healthcare, feedback was received by 
the regional team from several providers. This feedback related to delays in accessing 
timely equipment, to support ongoing care at home in the community and to enable a 
timely and effective discharge. 

To review, address and monitor these issues, weekly oversight meetings were initiated 
with  members  of  the  London  regional  team,  the  commissioners  of  the  equipment 
contract (Royal Borough of Kensington and Chelsea/Westminister City Council)  and 
key partners, to identify areas of concern, review core key performance indicators and 
monitor improvement trajectories. 

Current position 

Performance  has  improved  to  expected  contractual  levels  following  a  significant 
recovery/improvement process, but timings were set back due to the cyber-attack. 

Consortium-wide: 

•  88% “delivery in time” performance across the board. 
•  95% on “same day delivery” from Greenford depot, with >85% from Tottenham 

and Sidcup. 
“Next day” activities performing at 93% across consortium. 

• 
•  Key issues relating to stock management and visibility are largely resolved.  
•  Work to further refine the catalogue with clinical leads (occupational therapists) 

is in progress to:  
a)  ensure that all locally defined ‘special items’ are listed with ‘close technical 

equivalents’ clearly linked, and  

b)  reduce the number of products in key, high volume, order lines to enable 

NRS to manage the supply chain more effectively 

The statistics quoted above are from  the period of November 2024 but remain broadly 
consistent  and  refer  to  all  deliveries  across  the  catalogue  for  21  Boroughs. 
Commissioners are provided with a monthly picture of these performance metrics. 

NRS Healthcare actions 

 •  NRS Healthcare have mobilised significant additional senior management and 
executive  presence  to  oversee  and  ensure  that  the  London  Community 
Equipment  Consortium  contract  is  performing  and  meeting  the  needs  of 
prescribers, patients, and their families. 

•  Following earlier challenges with performance, NRS Healthcare implemented a 
refreshed complaints and escalation process for prescribers and local contract 
leads.  

•  During 2023/4, permission was granted for NRS Healthcare to use its Business 
Continuity Plan to invest in additional cleaning and recycling capacity at a site 
named London North. This assisted with reducing the backlog and increasing 
stock availability. 

•  Specific interventions have taken place at key sites and Boroughs experiencing 

challenges were identified.  

•  This  has  been  successful  in  identifying  and  addressing  issues  as  early  as 

possible.  

•  NRS Healthcare has appointed dedicated ‘Community Engagement Officers’ to 
build relationships with prescribers and provide support on-site where issues 
arise.  These  roles  have  been  particularly  helpful  working  with  teams  in 
Discharge Hubs at hospital sites and Community Health Trusts.  

•  Training  days  for  prescribers  have  been  made  available  by  NRS  Healthcare 

where specific needs have been identified.  

•  NRS Healthcare have been highly responsive when made aware of issues and 

see them through to resolution.  

Ongoing governance 

The  London  Community  Equipment  Consortium  has  robust  governance  in  place  to 
oversee the contract. This includes: 

•  Directors’ Board for key strategic decisions, meeting quarterly.  
•  Consortium for collective oversight of contract management, finances, and the 

NRS improvement plan, which meets monthly. 

•  Contract  Management  Board  for  local  contract  leads  to  hear  responses  and 
updates from NRS Healthcare, coordinated through the consortium team. This 
meets monthly. 

•  Regular  Equipment  Review  Groups  managed  by  a  Clinical  Lead  with 
Occupational Therapy representatives from across the consortium to manage 
the catalogue. This meets at least monthly. 

•  A series of workstreams established to address any live areas for development, 

including invoicing, IT, data validation, and stock controls. 

•  Access to community equipment is identified on the regional risk register and 

remains under monthly review.  

•  Fortnightly oversight meetings with ICB discharge leads and social care are in 
place  to  identify  any  specific  pathway  delays,  which  includes  any  related 
community equipment supply challenges. 

•  NHS  England’s  London  regional  team  continue  to  meet  with  the  equipment 
commissioners  and  key  partners  to  oversee  and  monitor  key  performance 
indicators, to support consortium members and associated providers. 

 North Central London Integrated Care Board 

North Central London Integrated Care Board (NCL ICB), who plan the health services 
in the area where Sheila was from, have also been undertaking significant work with 
the London Consortium and NRS Healthcare over the past year.   

NCL ICB advise that there were issues with the transfer of services from the previous 
provider  to  NRS  Healthcare.  The  cyber-attack  in  2024  suffered by NRS  Healthcare 
(referenced above) further exacerbated issues with their responsiveness to concerns, 
and issues with NRS Healthcare were escalated by providers in a timely way to the 
ICB  last  year.  Throughout  2023,  NCL  ICB  had  received  several  concerns,  patient 
safety incidents and complaints relating to the delivery and collection of equipment. 
However, the number of complaints has now reduced significantly in a relatively short 
space of time.  

The concerns were escalated to the London Regional Quality Group (part of formal 
NHS governance processes), where they have been escalated to the national team at 
NHS England and have been discussed at the regional Chief Nurses’ meeting. 

Although  improvements  have  been  made,  some  issues  continue  to  be  reported  by 
clinical teams in relation to the timeliness of delivery of equipment. Across NCL, these 
issues  are  managed  through  the  four  Local  Authorities  across  Barnet,  Camden, 
Haringey and Islington.  

NCL  ICB  have  supported  their  healthcare  providers  in  negotiations  with  NRS 
Healthcare, as well as LA colleagues, to resolve the issues, recognising that oversight 
and management of the contract and accountability is the responsibility of the London 
Community Equipment Consortium.  

I  would  also  like  to  provide  further  assurances  on  the  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  events,  such  as  the  sad  death  of 
Sheila, are shared across the NHS at both a national and regional level and helps us 
to  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

FAO Mr Ian Potter, Assistant Coroner 
Inner North London Coroner’s Court  
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

11 March 2025 

Dear Mr Ian Potter,  

INQUEST INTO THE DEATH OF SHEILA JOSEPHINE WEXLER (DATE OF DEATH 17 FEBRUARY 2024) 
RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

This is the response of Nottingham Rehab Limited (trading as NRS Healthcare) (“NRS”) to a Report to Prevent 
Future Deaths (“PFD Report”) dated 15 January 2025 which was issued under paragraph 7, Schedule 5, of the 
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The 
PFD Report was issued subsequent to an Inquest into the death of Mrs Sheila Josephine Wexler on 17 February 
2024 which the PFD Report states concluded on 14 January 2025.  

NRS offer their sincerest condolences to the family and loved ones of Mrs Sheila Josephine Wexler. 

NRS has set out below the context in which this response is provided. 

NRS was not aware of the Inquest until it received the PFD Report on 16 January 2025.  NRS had not previously 
been asked to provide a witness statement, or evidence of any kind to the Inquest.  It was not provided with any 
notification  of  the  Inquest  or  documentation  relating  to  the  matters  referenced  in  the  PDF  advance  of  its 
conclusion.  

On receiving the PFD Report and in order to understand the source of the issues it sets out and properly respond, 
NRS promptly wrote to the Assistant Coroner to request the transcript of Inquest and disclosure of documents. 
The Inquest bundle was subsequently disclosed to NRS, however the Coroner declined to provide the transcript 
of Inquest.  NRS has therefore not had access to the evidence heard by the Coroner during the Inquest. NRS has 
previously assisted Coroners in other Inquests and would have been happy to do so in relation to the death of 
Mrs Wexler. It would have welcomed the opportunity to provide relevant information to the Assistant Coroner to 
enable the Inquest to have all of the information about its involvement beyond that which appears to have been 
provided by unconnected third parties who had been designated as Interested Persons for the purpose of the 
Inquest. 

NRS notes that, before the conclusion of the Inquest and notwithstanding the matters identified by the Assistant 
Coroner in the PFD it had not been invited to participate as an Interested Person by virtue of either s.47(2)(f) or 
s.47(2)(m) of the Coroners and Justice Act 2009.  

NRS regrets not having been provided with that opportunity and the consequence is that a PFD has been issued 
containing matters that NRS may have been able to clarify and means, of course, that it is not privy to the evidence 
heard at the Inquest and that is explicitly referenced in the PFD Report relating to NRS operations.  

An example of the difficulty created in responding to the PFD when NRS has not had the opportunity to hear the 
evidence at the inquest is that the PFD contains a reference to the Coroner being told “that the service provided 
was still ‘not great’”.  It is clear that this statement during the hearing was a consideration for the Assistant Coroner 
in issuing the PFD.  Similarly the PFD references the Coroner hearing evidence of “numerous and ongoing delays 

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB 

NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and ‘problems’ in the service provided by NRS Healthcare”.  However, on the face of the PFD these concerns 
appear anecdotal and it is respectfully submitted that they are too vague for NRS to be able to properly respond 
to without having heard the context in which these comments were made. 

In view of the context set out above, this response therefore is made to the best of NRS’ ability in seeking to 
address the concerns raised in the PFD Report insofar as they relate to NRS operations.  

It may be relevant to note that NRS was victim of a significant cyber-attack in April 2024 which hinders access to 
some, but not all, previous records. 

Response to concerns regarding the provision of equipment to Mrs Wexler 

It is important to note at the outset that NRS is a specialist provider of community equipment to people across the 
UK  on  behalf  of  the  NHS  and  Social  Care.  NRS  install,  deliver,  maintain  and  recycle  such  equipment.  The 
equipment itself is prescribed by healthcare professionals and others authorised to do so who work in the NHS 
and for Local Authorities. NRS does not have any role in assessing people’s needs. NRS operates an electronic 
catalogue  of  all  care  items  that  Commissioners  and  Contract  Leads  for  London  have  requested  that  NRS 
Healthcare hold.  This equipment can only be ordered by NHS or Social Care prescribers. No other equipment is 
available to NRS or its Community Equipment Technicians. 

To address the concerns of the Coroner, NRS has set out below key aspects in the chronology of the provision 
of equipment to Mrs Wexler, which is derived from available NRS records and statements provided to the Inquest 
by others and provided in the disclosure bundle. 

The products relevant to the PFD which were ordered from NRS and provided to Mrs Wexler by NRS during the 
relevant  time  period  were  a  TOTO  lateral  turning  system  and  a  Dynamic  Mattress.  NRS  notes  that  the 
manufacturer’s  information  regarding  both  of  these  items  of  equipment  references  that  they  are  prescribed  to 
treat and prevent pressure ulcers. They are not prescribed to prevent a pulmonary embolism.  

NRS has not been provided with any medical evidence linking the provision of equipment for pressure ulcers with 
the development of a pulmonary embolism and is therefore unable to comment on this concern in the PFD.  

The PFD report suggests an initial delay in the delivery of equipment. This is not accepted by NRS. Its records 
show a  next day order was received on 10 January 2024 at  17.17. The order  was for a Dynamic Mattress, a 
TOTO turning system (“TOTO”) and side bumpers. The cut off for next day orders is 17:00 and therefore the ‘next 
day’ for an order placed at 17:17 on 10 January is 12 January. The delivery of the Dynamic Mattress and TOTO 
was made on 12 January.  The bumpers could not be installed as side rails had not been ordered by the prescriber 
for  the  bed.  The  order  for  bumpers  was  cancelled.  On  12  January  a  same  day  order  was  received  from  the 
prescriber for side rails and these were delivered that day. The position therefore on 12 January was that a brand 
new (not refurbished) Dynamic  Mattress, TOTO and  side rails were in place and had been  delivered by NRS 
within the service agreement timescale. 

The statement of 
in the hospital bed with the TOTO on. No concerns were noted on this date. 

, Tissue Viability Specialist Nurse confirms that on 18 January Mrs Wexler was 

NRS records show that a visit was made by one of its out of hours Community Equipment Technicians on 21 
January who was at the property for 15 minutes. The available notes on the NRS system do not state what action 
was taken on that visit and this does not seem to be addressed in the Inquest bundle statements. 

On 22 January NRS records show that a call was received by NRS to state that either the Dynamic Mattress or 
the  TOTO  were  not  working.  An  NRS  Community  Equipment  Technician  visited  that  day,  swapped  both  the 
Dynamic  Mattress  and  the  TOTO  and  tested  both  before  leaving  the  premises.  NRS  records  show  that  the 
Dynamic Mattress and TOTO were both tested by NRS after collection, as is standard practice to establish what 
repairs are required before reuse. Neither piece of equipment was found to have a fault. 

From  23  January  to  29  January  (inclusive)  no  calls  are  recorded  by  NRS  as  having  been  received  by  them 
regarding malfunctioning equipment. It is clear from the statement of 
 that the district nursing team 
undertook regular visits and this included 23 and 27 January.  NRS is confident that a fault in the equipment would 

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB 

NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 have been obvious to the District Nurse and they would have reported this to NRS. No such concern was raised 
 (Tissue Viability Nurse) 
and the statements of 
also do not state a concern was raised to NRS at this time by any medical staff or by the family. There is a slight 
discrepancy between the Inquest statement of 
, which states that Mrs Wexler’s daughter said 
NRS attended on 23 January and NRS notes, which record that the Community Equipment Technician attended 
on 22 January. NRS cannot explain this discrepancy. Regardless, no other report of a concern was made to NRS 
until 30 January. 

 (District Nurse Team Leader) and 

On 30 January at 14:08 NRS records show a request was made for a same-day repair of the TOTO due to the 
user being unable to adjust the settings or timings. This was reported by the District Nurse Team Lead, 

.  The Community Equipment Technician attended at 16:06 and notes are that there was no answer at the 
property. On 31 January NRS phoned the daughter at 12:45 and there was no response. On 1 February contact 
was  made  and  a  visit  arranged  for  2  February.  On  attending  the  property  the  NRS  Community  Equipment 
Technician  noted  that  Mrs  Wexler  was  asleep  and  they  were  unable  to  inspect  the  equipment.  The  daughter 
requested that the Community Equipment Technician returned the following morning. The Community Equipment 
Technician  returned  the  following  morning  on  3  February.  They  noted  that  a  further  visit  was  required  for  the 
repair to the TOTO to be undertaken and this visit was made on 5 February with the repair being noted as made. 

A Dynamic Mattress in working order was at the property for the complete time period. The Dynamic Mattress 
itself has its own pump which is separate from the TOTO and for this reason the Dynamic Mattress would have 
provided  pressure  relieving  qualities  while  in  use.  The  TOTO  is  a  turning  system  is  installed  underneath  the 
mattress to provide a turning platform which provides additional pressure relief for those unable to adjust their 
own position in bed.  

In summary the timeline established from NRS records is: 

From 12 January- 29 January (inclusive), the Dynamic Mattress and TOTO were at the property and in working 
order, having been installed by an NRS Community Equipment Technician on 12 January.  The possible exception 
to  this  is  21-22  January  when  replacement  equipment  was  ordered  and  provided.  However,  the  equipment 
removed from the property at this time was found to be in working order on inspection. 

Between 30 January -5 February several visit attempts were made which related to the TOTO only, with this being 
repaired on 5 February.  

Tri-Pos Bariatric Alternating Air Cushion Pump 

The PFD report states that “An engineer attended Mrs Wexler’s home, on behalf of NRS Healthcare, to repair the 
equipment but used a pump that was not compatible with the turning system.” The statement from 
suggests the incompatible equipment was a Tri-Pos Bariatric Alternating Air Cushion Pump. 

This pump is not one which is supplied by NRS. It is not available on the equipment catalogue and therefore not 
possible  for  it  to  either  be  ordered  by  a  prescriber  or  supplied  to  a  service  user  by  a  Community  Equipment 
Technician. An online search shows that this pump is publicly available as a rental product. 

The Community Equipment Technician attending Mrs Wexler’s address is very experienced and has completed 
training  on  the  TOTO.  NRS  has  taken  very  seriously  the  allegation  that  the  NRS  Community  Equipment 
Technician  replaced  the  TOTO  pump  with  one  not  available  through  NRS  and  has  spoken  to  the  Community 
Equipment Technician concerned. The Community Equipment Technician has confirmed that he recalls attending 
the property and replacing the TOTO pump with another TOTO pump. He confirms that he did not see anot her 
pump and had no method of accessing equipment other than that on the NRS catalogue.   

 with photos of the Tri-Pos Bariatric Alternating Air 
NRS is unable to retrieve the email sent by 
Cushion Pump and we note it does not appear in the Inquest disclosure. NRS acknowledge they may not be able 
to retrieve this due to the cyber-incident. 

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB 

NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 NRS therefore does not accept that it was responsible for the installation of the Tri-Pos Bariatric Alternating Air 
Cushion Pump.  

In summary: 

• 

• 
• 
• 
• 

NRS is not a prescriber of equipment. Equipment can only be supplied by NRS if it is ordered from 
NRS by a prescriber.  
NRS only supplies equipment in an approved catalogue. 
NRS Community Equipment Technicians only have access to equipment in the catalogue. 
The Tri-Pos Bariatric Alternating Air Cushion Pump has never been available in the NRS catalogue. 
It is therefore impossible for the Tri-Pos Bariatric Alternating Air Cushion Pump to have been ordered 
from NRS by a prescriber or supplied by an NRS Community Equipment Technician. 

Service Improvements  

NRS took over the contract to supply 21 London Boroughs with healthcare equipment in April 2023. Since taking 
over the contract NRS has taken significant steps to evolve and improve the quality of customer services and 
equipment provided to service users.  

This includes; 

• 
• 

• 

• 
• 

• 
• 
• 

Providing additional training to all customer service operatives; 
Enhancing the  working arrangements  between  customer service  operatives and  the  management 
team in service centres; 
Reorganisation of Community Equipment Technician teams so they are focused on individual London 
Boroughs; 
Instigation of a daily debrief and feedback on any unsuccessful activity; 
Improved communication from Community Equipment Technician to managers when they have been 
unable to make contact with a service user at the premises;  
An improved communications process with hospital discharge teams; 
A new performance monitoring system; and 
Improvements to the product ordering system to make it clearer which equipment is in place.  

Additionally, on 07 August 2024, The London Community Equipment Consortium completed an equipment review 
of lateral turning systems to evaluate what is currently available on the standard catalogue. During the  review 
seventeen clinicians reviewed five lateral turning systems from three suppliers/manufacturers. A full market scope 
was conducted to compile a list of all relevant suppliers and products. A shortlist of products was compiled to 
review in person, based on an expert Tissue Viability Nurse undertaking a desktop review. The result of the review 
is that the TOTO should be phased out over time and not reissued to service users, gradually replacing these 
with a turning system which performed better in the review. 

NRS hope that this information has provided clarity to the Coroner subsequent to issuing the PFD Report. NRS 
also hopes that notwithstanding the fact that NRS does not accept the concerns in the PFD report, for the reasons 
described, actions have been undertaken and continue to be undertaken by NRS to improve its service. 

Yours sincerely 

Chief Community Services Officer 

Nottingham Rehab Limited 

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB 

NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041