Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0084, written 6 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Feb 2025 |
|---|---|
| Reference | 2025-0084 |
| Deceased | Katrina Insleay |
| Coroner | James Puzey |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive(s) of Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust 1 CORONER I am James Puzey, assistant coroner, for the coroner area of Worcestershire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 10 January 2024 HMSC David Reid commenced an investigation into the death of Katrina Veronica Francesca Insleay, aged 90. The investigation concluded at the end of the inquest on 12 December 2024 which I heard. The conclusion of the inquest was that the medical cause of death was Sepsis due to an infected sacral pressure sore and pneumonia. CIRCUMSTANCES OF THE DEATH 4 1. Katrina Insleay died on 1 January 2024 at the Alexandra Hospital, Redditch from sepsis due to an infected pressure sore and pneumonia. Ms. Insleay went into hospital on 18 November 2023 with what was a low-grade pressure sore. She remained under the care of hospital clinicians or community health professions from that point until she died on 1 January 2024 and during that time the condition of her pressure sore became worse and she developed sepsis therefrom. 2. Evidence was given at the inquest by a Clinical lead with the Pershore and Upton Neighbourhood team that Ms Insleay was discharged home from Worcestershire Royal Hospital on 4 December 2023 and that the Pershore and Upton Neighbourhood Team received a telephone call from the patient discharge unit at the hospital that day. Information received was that Miss Insleay had a grade 2 pressure to her sacrum which had developed in hospital. The Neighbourhood team were asked to visit the patient on Thursday 07/12/2024 to redress the sacral pressure ulcer and check the hip wound. They were advised that the sacral pressure sore should be redressed twice weekly. A visit was planned for the 07/12/2024. In fact, the pressure sore was at least a grade 3. I was told that pressure sore assessment is, to a degree a subjective exercise of judgment but the evidence in this case was that the grading of the sore by the hospital as a grade 2 was clearly wrong. 3. 4. As it happens the Neighbourhood Team visited on 5 December 2023 because it was reported to them that the dressing had come away 1 from the wound. However, owing to miscommunication the results of the swaps taken of the pressure sore were not acted upon promptly and the pressure sore developed an infection which became worse and sepsis was the result. 5. The evidence from the clinical lead was that the Neighbourhood Team (“NT”) and the Hospital had completely different record keeping systems and the NT could not simply check the hospital records without specifically requesting them. The handover between hospital and NT for patients being discharged from hospital was often by telephone and only sometimes was there a handwritten form. There was no formal, documented handover procedure that was capable of being checked. The NT did not always receive the discharge letter. The images of Ms Insleay’s wound that were taken at the hospital were not available for the NT to view unless they specifically requested them. Consequently, absent the dressing becoming loose, there would have been no visit between 4 and 7 December 2023 and the actual state of the pressure sore would not have been observed until even later. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and for follow up to be delayed. This increases the risk of wound infection and consequent sepsis. (2) I am informed (letter received from HWHCT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and I am also under a duty to send the Chief Coroner a copy of your response. 2 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 6 February 2025 HMAC James Puzey 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Chief Executives Office
2 Kings Court
Charles Hastings Way
Worcester
WR5 1JR
Tel: 01905 681667
Email:
www.hacw.nhs.uk
Ref:
3rd April 2025
Dear Sir,
Acting Chief Executive
Worcester Acute Hospitals NHS
Trust
Executive Suite
Sky Level 3
Charles Hastings Way
Worcester
WR5 1DD
Tel:
Email:
Re Inquest touching the death of Katrina Insleay
In a Regulation 28 Order dated 13th February 2025, HMAC Puzey raised the following
concerns:
(1) The absence of a formal, documented handover system between hospital and
Neighbourhood Team and the fact that the NT cannot simply check hospital
records of patients with pressure sores to verify their condition without
specifically requesting records creates the potential for the NT to fail to
appreciate the true condition of a patient's pressure sores when they are
discharged from hospital and for follow up to be delayed. This increases the
risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHCT on 31.1.25} that there are
established handover procedures and that a statement of practice is being
drafted to "formalise" the referral requirements between hospital and NT. l am
informed also that an App is being developed which can be used to record and
check the condition of pressure sores and that it has the potential to be used
across acute and community services. I do not consider that these proposals
are sufficiently detailed, precise and concluded to address the concerns that I
have expressed.
The Trusts have already provided a response to the Coroner’s initial letter of concern, and
therefore will focus on further developments since then in this response.
Response to concerns
The Trusts have further considered the impact of not having a shared records system, and
the Health and Care Trust are in the process of obtaining access for 2 members of staff per
Neighbourhood team (including Evening and Nights community nursing team) to the Acute
Trusts Electronic Patient Record – ‘Sunrise’. The access will be given to staff who sit within
Triage hubs in the Neighbourhood Teams and triage new referrals. This will enable them to
gain detailed patient information, for example, regarding wounds.
So far, 18 out of the 26 people identified as needing access, have been granted access but
are not yet in full operational use. Once all access has been obtained as planned, this will be
reviewed quickly to establish whether more licenses are required.
In addition, the Acute Trust have developed a handover form (copy attached), which will detail
wound care advice taken from the information on ‘Sunrise’ within the nursing and Tissue
Viability records. This will be sent home with the patient and therefore will be available for
them to share with professionals who attend their home, as an additional source of information
alongside the Electronic Patient Record system.
These steps are in addition to the measures already outlined in the Trusts earlier letter.
I confirm that I have not forwarded a copy of this response to any other Interested Person and
would therefore be grateful if you could do so, as appropriate.
I also confirm that the Trusts are content for both the regulation 28 report and the response
to be released or published should the Chief Coroner wish.
Yours sincerely
Chief Executive
Herefordshire & Worcestershire Health & Care NHS Trust Worcestershire Acute
Hospitals NHS Trust
Acting Chief Executive
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