Margaret Rodgers

Trust Headquarters 
East Surrey Hospital 
Canada Avenue 
Redhill 
RH1 5RH 

Tel: 01737 768 511 
www.surreyandsussex.nhs.uk  

15 April 2025 

HM Assistant Coroner Ms Ridge  
Woking Coroner's Court 
Station Approach  
Woking 
GU22 7AP  

Dear Madam 

Re: Regulation 28 Report to Prevent Future Deaths – Margaret Rodgers  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19  February  2025 
concerning the death of Margaret Rodgers. In advance of responding to the specific concerns raised 
in  your  Report,  I  would  like  to  express  my  deep  condolences  to  Margaret's  family  and  loved  ones. 
Surrey  &  Sussex  Healthcare  NHS  Trust  are  keen  to  assure  the  family  and  the  Coroner  that  the 
concerns  raised  about  Margaret's  care  and  the  circumstances  surrounding  her  death  have  been 
listened to and reflected upon.   

The  first  concern  raised  was  as  follows:  'NICE  and  the  National  Wound  Care  Strategy  guidance  is  that 
patients admitted to hospital have a pressure ulcer risk assessment within 6 hours of admission. This means that 
the first assessment will often need to be undertaken in the Emergency Department (ED). The court heard that 
the work to ensure that the ED completes such assessments is ongoing and not yet embedded and that there are 
practical difficulties, for example when ED patients were located on corridors.' 

The Trust has considered this concern carefully and we enclose a copy of our Emergency Department 
action plan, with reference to the pertinent points below. This action plan has been in place since May 
2024 and was implemented to assist with extended patient stays in the Emergency Department (ED) 
in a post-covid environment.  

An Associated University Hospital of 
Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 1)  Purpose T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) training  

Purpose T is a nationally used tool to identify patients who are at high risk of developing pressure 
damage. Once a patient is identified as high risk, Purpose T prompts a set of assessments which 
need  to  be  carried  out  by  the  nurse  caring  for  the  patient,  including  history  of  pressure 
intake,  diabetes,  perfusion,  moisture  damage  and  sensory 
damage/ulcers,  nutritional 
perception. It also prompts nurses to consider whether the patient has capacity if they refuse to 
be  assessed,  and  acting  in  the  patient’s  best  interests  if  they  are  unable  to  consent  to 
examinations and assessments.  

Purpose T is a more in depth tool to use with greater consideration of a patient’s individual risk 
factors than, for example, the Waterlow score. 

2)  Cerner prompts and ClinOps 

Any patient tasks/assessments that have not been completed are flagged  as outstanding and 
create a pop-up reminder for anyone accessing the patient’s records on Cerner. For example, if 
the Purpose T assessment has not been completed then Cerner will prompt the nurse that it 
needs to be carried out when they access the records. 

In addition to individual reminders, an overview of every ward and patient is available on the 
Ward  View  Nursing  Production  Board  on  ClinOps,  which  is  overseen  by  Matrons  and  ward 
managers. This is a projection board which shows every patient who is breaching for any reason 
and is mainly utilised by managers to have oversight of the whole ward/department. The board 
highlights outstanding tasks for each patient, which are seen as an overview bar flagged red. 

Matrons monitor the Ward View Nursing Production Board to ensure “every day is a green day”, 
whereby  the  expectation  is  that  by  the  end  of  a  nursing  shift  all  tasks/action  for  the  nurse’s 
patients should be green (i.e. completed).  When commencing a new shift and taking over care 
of patients from another member of staff, the same list will form the nurses to do list for that 
patient. 

It is important to note that patients receiving “corridor care” are always allocated to a nurse. The 
allocation is to the same ratio of staff to patients as it is if the patient was in the main Emergency 
Department. Similarly, the projection board will flag to management any outstanding tasks or 
assessments  for  corridor  care  patients  in  the  same  way  would  if  the  patient  was  located 
elsewhere in the hospital. 

3)  Train the trainer programme and a targeted teaching approach 

All  new  ED  staff  receive  training  on  pressure  damage  and  pressure  care  as  part  of  their 
mandatory  training  when  they  commence  work  at  the  Trust.  However,  it  is  recognised  that 
nursing staff cannot be removed from ED to attend training sessions as easily as they could be 
on inpatient wards. When Purpose T was first introduced an intensified training programme was 
included in ED which allowed nursing staff to be trained alongside their day to day work. This 

An Associated University Hospital of 
Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 targeted approach included having a Practice Development Nurse on the shop floor in ED for 
two weeks to assist staff as they carried out their assessments and familiarised themselves with 
the new system. Train the trainer allows for clinical staff to be trained in certain competencies 
and to then train their colleagues utilising their new skills, and has been completed for bands 3-
7. 

In addition, Purpose T also has a guidance section to assist in completing the assessments. 

All ED staff have completed Purpose T training, including those employed via agency. 

4)  Nurse Quality Rounds 

These are designated rounds at 2 hourly intervals involving the band 7 nurse in charge, 
Matron and PDN (all three are not required for the round). They do an eyeball assessment on 
every patient, including those receiving corridor care, with the aim of supporting staff to ensure 
tasks and assessments are completed. The purpose of the round is to provide an additional 
level of safety netting as they may pick up something that a less experienced nurse might 
miss. Junior staff can also ask questions and seek guidance on any assessment their patient 
needs which they are unclear about. 

The Practice Development Nurses in ED are supernumerary (do not have their own caseload 
of patients). They monitor and provide support to nursing staff to complete assessments that 
are outstanding. PDNs will also look at accuracy of any assessments undertaken. 

The expectation is either the Matron or PDN will oversee that all patients are assessed as 
required and they receive their medication.  

5)  Planned audits to monitor progress relating to compliance in the ED 

At present the systems referred to above are only available as a live version and so we aren’t 
able to audit compliance currently. We are working with the Trust’s informatics team to build a 
report whereby compliance can be monitored and audited. 

The second concern was as follows: 'The court also heard that in December 2023 to January 2024, the period 
of  Mrs  Rodgers  admission,  the  hospital  was  experiencing  a  high  level  of  operational  pressures  and  that  on 
occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high 
dependency needs. The Trust is undertaking a review of the staffing template for the ward, but that work is not 
complete and not yet incorporated into the budget.' 

1)  NHS England mandates evidence-based decision making for safe and effective staffing across 
all  NHS  organisations.  All  Trusts  are  required  to  conduct  a  biannual  review  of  their  ward 
establishments using the Safer Nursing Care Tool. At SASH, we have been carrying out this 
review on all wards for the past 18 months. While the results of the review and any necessary 

An Associated University Hospital of 
Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 staffing increases have not yet been reflected in the ward budgets, Nutfield Ward has addressed 
this by incorporating additional shifts into the roster template and utilising temporary staffing. 

2)  Staffing levels on Nutfield ward are 5 qualified nurses and 3 non-qualified staff during the day, 
and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have 
an extra nursing assistant than the template allows and this was recognised through the need 
for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess 
the acuity on wards on a daily basis and will use clinical decision making to ensure that wards 
are safe, if there are any concerns they will escalate to senior management and additional staff 
will be requested for that shift if necessary. We are also able to move staff to work on different 
wards if acuity requires it.  

The Trust holds twice daily safer staffing huddles, attended by the Head of Nursing or a matron 
representative. During these meetings, each division reports staffing levels, mitigation actions 
taken,  and  any  remaining  gaps.  The  staffing  situation  is  reviewed  using  the  Safe  Care  Live 
system to identify potential cross-divisional moves or the need for temporary staffing. If these 
options are insufficient, corporate nursing teams are deployed to provide clinical support. The 
meeting  also  reviews  staffing  for  the  next  day  and  on  Fridays  the  weekend  staffing  is  also 
considered.  If  staffing  issues  cannot  be  resolved,  they  are  escalated  to  the  Chief  Nurse  for 
further action. 

The Trust would like to thank you again for bringing these issues to our attention and should you require 
any further clarifications, please do not hesitate to contact us via our legal services department.  

Yours sincerely,  

Chief Medical Officer 

An Associated University Hospital of 
Brighton and Sussex Medical School