Christopher Bradbury

Ms Emma Serrano 
HM Area Coroner  
Stoke-on-Trent and  
North Stafforshire Coroner’s Service 
Stoke Town Hall  
Kingsway 
Stoke-on-Trent 
ST4 1HH 

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

6 May 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Christopher Glanville 
Bradbury who died on 5 January 2024.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  11 
March  2025  concerning  the  death  of  Christopher  Glanville  Bradbury  on  5  January 
2024. In advance of responding to the specific concerns raised in your Report, I would 
like  to  express  my  deep  condolences  to  Christopher’s  family  and  loved  ones.  NHS 
England are keen to assure the family and the Coroner that the concerns raised about 
Christopher’s care have been listened to and reflected upon.   

The first matter of concern raised in your Report was that there is a national lack of 
knowledge  and  guidelines  of  severe  invasive  soft  tissue  infections,  that  are  not 
necrotising fasciitis.  

The responsibility for clinical guidance sits with the National Institute for Health and 
Care  Excellence  (NICE)  and  the  current  relevant  guidance  is  available  here: 
https://www.nice.org.uk/guidance/conditions-and-diseases/infections/skin-
infections/products?GuidanceProgramme=guidelines.  NICE  have  also  produced  a 
Clinical Knowledge Summary (CKS) on impetigo and cellulitis, which include treatment 
options for severe infection and referral/escalation criteria for specialist input.  

The  UK  Health  Security  Agency  (UKHSA)  are  also  responsible  for  surgical  site 
infection  (SSI)  surveillance,  guidance,  data  and  analysis,  which  includes  escalating 
matters to providers where appropriate. You may therefore wish to refer your concerns 
to NICE and/or the UKHSA.  

There is an opportunity this year to revisit statutory and mandatory training for infection 
and prevention control and my Antimicrobial Resistance colleagues will seek to ensure 
emphasis on escalation of deteriorating patients.   

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions 
that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging 
from  simple  superficial  infections  to  severe  necrotising  infections.  The  diagnosis  of 
necrotising  soft-tissue  infections  (NSTIs)  is  primarily  clinical,  although,  radiologic 
imaging may be able to provide useful information when the diagnosis is uncertain. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
  
 However,  it  is  important  that  if  clinical  suspicion  of  NSTI  is high,  radiologic  imaging 
must  neither  delay  nor  deter  surgery,  because  in  this  setting  an  early  surgical 
debridement is essential to decrease mortality. 

Your  second  concern  was  that  actions  identified  in  the  Patient  Safety  Incident 
Investigation (PSII) have not made significant inroads or been effective. I note that you 
have also sent your Report to the Royal Stoke University Hospital and it is appropriate 
that they or University Hospitals of North Midlands (UHNM) NHS Trust to respond to 
you regarding this concern. NHS England Midlands regional colleagues are also in the 
process  of  engaging  with  Staffordshire  and  Stoke-on-Trent  Integrated  Care  Board 
(ICB),  the  commissioner  of  UHNM,  on  the  concerns  raised  by  your  Report  for 
assurance purposes.  

Your Report also raised the concern that there is no audit trail if a patient is not given 
their  medication,  because  no  signature  is  required  for  the  option  of  recording  an 
‘Omitted Dose’.  

Prescribing  information  for  soft  tissue  infections  via  the  British  National  Formulary 
(BNF), which provides key information on the selection, prescribing, dispensing and 
administration  of  medicines  for  healthcare  professionals,    is  available  here: 
https://bnf.nice.org.uk/treatment-summaries/skin-infections-antibacterial-therapy/ 

Electronic  Prescribing  and  Medicines  Administration  (EPMA)  systems  eliminate  the 
lack  of  signature  and  accountability  issue  raised  by  the  Coroner  because  a  person 
would need to be logged into the system to record a missed dose and there would 
therefore  be  the  requirement  of  a  digital  signature.  Within  EPMAs  there  is  also  the 
facility to include alerts that would prompt the person recording a missed dose if this 
were a critical drug that shouldn’t usually be omitted.  

All NHS Trusts should be moving towards digital EPMA systems, which will mitigate 
the risk of accountability for missed doses. In the absence of a signature for a missed 
dose, it should still be possible to identify nursing staff responsible for the care of a 
patient at any given time and therefore responsible for administering medicines and 
identifying  and  escalating  risks  such  as  delays  to  antibiotic  treatment  of  serious 
infections.  The  Nursing  and  Midwifery  Council’s  Code  of  Practice  makes  clear  that 
patient records must be kept clear and accurate, and ‘identify any risks or problems 
that have arisen’.  

It is not possible for NHS England to provide further comment based on the information 
provided in your Report.  

I would also like to provide further assurances on 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  Christopher,  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

Trust Ref:

14 April 2025 

STRICTLY PRIVATE & CONFIDENTIAL 
Ms Emma Serrano 
Area Coroner 
Stoke on Trent and North Staffordshire 

Royal Stoke University Hospital 
Executive Suite 
Springfield 
Newcastle Road 
Stoke-on-Trent 
Staffordshire 
ST4 6QG 

Tel: 01782 676631 

Sent via email: 

Email: 

Dear Ms Serrano 

Christpoher BRADBURY   

Further to your letter dated 11 March 2025, I am pleased to provide a response under paragraph 7 of Schedule 
5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroner’s  (Investigations) 
Regulations 2013, addressing your concerns surrounding the death of Christopher Bradbury.  

Recorded Circumstances of the Death 

On  the  28  December  2023  Christopher  Granville  Bradbury  fell  at  his  home  address  and  sustained  a  cut 
between his two small toes on the right foot.  

He  was  admitted  to  the  Royal  Stoke  University  Hospital,  Stoke-on-Trent,  on  the  2  January  2024.  He  had 
symptoms of diarrhoea and vomiting, and it was reported that he had collapsed. He has a lesion on his little 
toe on his right foot and swelling to his right leg. On examination he was placed on the SEPSIS 6 pathway, 
and treated in accordance with this. He was examined by an Orthopaedic registrar who ordered an urgent 
MRI scan, to ascertain the cause of the swelling and the lesion.  

On the 4 January 2024, with no MRI scan being done, he received a Consultant review and a diagnosis of 
Invasive Soft Tissue Infection was made. He was too ill for a MRI scan and was taken directly to theatre for a 
below the knee amputation.  

After the surgery, he did not recover and passed away on the 5 January 2024. There was an opportunity for 
Mr Bradbury to be given a MRI scan, and if this had taken place, he would have been diagnosed earlier, and 
received the operative intervention at an earlier stage. It cannot be said that this would have made a difference 
to the outcome for Mr Bradbury. 

It  was accepted  in evidence  that  the  issue  giving  rise  to  the  delay in  the MRI  scan  was down  to a lack of 
knowledge  of  Severe  Invasive  Soft  Tissue  Infections,  that  are  not  (but  are  closely  related  to)  necrotising 
fasciitis.  It was accepted in evidence that there is a lack of national Guidelines on this. It was accepted in 
evidence that the large number of Drs expected to specialise in this, made it almost impossible for them to be 
taught about this. 

. 

 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 The evidence given was that training is being delivered continuously, and the actions from the PSII have been 
carried out but this is not making significant inroads, it had not been effective at all, and it is thought that this 
will happen again.   

It  was  accepted  in  evidence  that,  when  signing  medication  out,  at  the  hospital,  if  the  medication  is  not 
available, no signature is required when choosing option 5 “omitted dose”.  This means that there is no audit 

trail, if a patient is not given their medication, because it is unavailable, or omitted for some other reason. 

Concerns 

During  the  course  of  the  inquest,  you  felt  that  evidence  revealed  matters  giving  rise  for  concern.  In  your 
opinion, matters for concern are as follows. 

1.  A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely 
related  to)  necrotising  fasciitis  combined  with  a  lack  of  national  Guidelines  on  this.  This  being 
exacerbated by the large number of Drs expected to specialise in this. 

2.  The evidence given was that training is being delivered continuously, and the actions from the PSII 
have been carried out but this is not making significant inroads, it had not been effective at all, and it 
is thought that this will happen again.  

3.  When signing medication out, at the hospital, if the medication is not available, no signature is required 
when choosing option 5 “omitted dose”.  This means that there is no audit trail, if a patient is not given 
their medication, because it is unavailable, or omitted for some other reason. 

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  

In your opinion, action should be taken to prevent future deaths.  

Action Taken 

The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest 
seriously and indeed, I am grateful that you have raised your concerns to which a response is provided below. 

1.  We recognise and share the Coroner’s concern regarding the national lack of awareness and guidance 
relating specifically to Severe Invasive Soft Tissue Infections (SISTIs) that are not necrotising fasciitis, 
but have similar aggressive and life-threatening characteristics. 

As  an  individual  NHS  organisation,  we  are  not  directly  responsible  for  developing  national  clinical 
guidelines, however, we would fully support any national work to raise awareness of these rare but 
serious  infections,  and  the  development  of  clear  diagnostic  and  management  guidance.  We  also 
accept the challenge presented in ensuring wide clinical awareness of rare conditions, particularly in 
environments  where  staff  rotate  frequently,  and  experience  may  be  limited.  This  challenge  is 
compounded  further  by  the  relative  rarity  of  such  presentations,  meaning  that  many  clinicians  may 
never  have  encountered  a  case  during  their  training  or  practice.  Nevertheless, 
  will 
continue with the important work he is undertaking in this area. 

2.  Within our Trust, we continue to take the issue of training very seriously. We have already undertaken 
a significant programme of training and learning following this case, ensuring key themes and learning 
have been widely shared across our clinical teams. 

. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 We  are  committed  to  continuing  this  education,  both  through  formal  teaching  and  case-based 
discussions.  However,  again,  we  do  recognise  that  due  to  the  rarity  and  complexity  of  these 
presentations, training alone will not always ensure early recognition. To that end, we will continue to 
emphasise the importance of early escalation and senior clinical review where there is any concern 
about deteriorating soft tissue infections. We believe that early involvement of senior decision-makers, 
particularly  consultants  who  may  have  greater  experience  with  rare  or  atypical  presentations,  is 
imperative to supporting early diagnosis and appropriate intervention. 

3.  With regard to the concern raised about medication omissions and the lack of an auditable trail when 
a dose is not administered, I can confirm that currently we do not have an Electronic Prescribing and 
Medicines Administration (EPMA) system in place at our Trust. 

However, the Trust is in the process of implementing EPMA across both our sites. Once implemented, 
EPMA will provide a robust and transparent record of all medication activity, including when a dose is 
omitted, the reason for omission and the identity of the person making that decision. 
When we have our EPMA system, the electronic chart will capture everything in one place.  

In the interim, we have developed a Patient Safety Learning Alert requiring staff to document reasons 
for drug omissions. These omissions are to be documented within the relevant  patient record. This 
alert has been circulated to all staff and is enclosed for your review. 

The  implementation  of  our  EPMA  will  significantly  improve  the  governance  and  auditability  of  our 
medicines management across the Trust and directly addresses the concern raised in the Regulation 
28 report. 

We do hope that the above information provides assurance that the Trust has taken the concerns raised at 
the inquest seriously and that both you and Mr Bradbury’s family are content with the response that has been 
provided.  

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. 

Yours sincerely, 

Chief Executive 

.