Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0166, written 1 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Apr 2025 |
|---|---|
| Reference | 2025-0166 |
| Deceased | Mary Pomeroy |
| Coroner | Nicholas Lane |
| Coroner area | Devon, Plymouth and Torbay |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth 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.
COUNTY OF DEVON, PLYMOUTH AND TORBAY CORONER AREA REPORT ON ACTION TO PREVENT OTHER DEATHS MARY MARGARET POMEROY HM AREA CORONER NICHOLAS LANE REGULATION 28 – REPORT ON ACTION TO PREVENT OTHER DEATHS THIS REPORT IS BEING SENT TO: 1) (Interim Chief Executive Officer) and - University Hospitals Plymouth NHS Trust (UHP NHS) Via email: for UHP NHS) and (instructed external legal representative at inquest (deputy legal manager, UHP NHS) (Chief Nursing Officer) 1 2 CORONER I am Nicholas Lane, HM Area Coroner for County of Devon, Plymouth and Torbay coroner area. 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: e http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 25 March 2022 an investigation was commenced into the death of Mary Margaret Pomeroy. The investigation concluded at the end of the inquest hearing on 25 March 2025 at Exeter Coroner’s Court, in Area. the Plymouth Coroner County Devon, Torbay and of 4 CIRCUMSTANCES OF THE DEATH Mary Pomeroy was a frail 89 year old female who suffered fatal traumatic injuries that were inflicted upon her (following being pushed over and falling to the ground) by a fellow in-patient on their shared ward at Derriford Hospital, Plymouth in March 2022. Section 2 of the Record of Inquest (which recorded the medical cause of Mary Pomeroy’s death) was determined as: 1a – combined physiological effects of bilateral humeral fractures in an elderly patient 1b – traumatic fall to ground following being pushed over Section 3 of the Record of Inquest (which answered how, when and where Mary Pomeroy came by her death) was determined as: ‘Mary Pomeroy was an in-patient at Derriford Hospital, Plymouth when, on 3 March 2022, she was pushed over on to the floor by a fellow patient who had been suffering with psychotic symptoms and cognitive and behavioural problems. Mary suffered fractures as a result of this trauma. Mary’s condition deteriorated after, and as a direct result of, this incident, and she died on 15 March 2022 at Derriford Hospital, Plymouth. There was a lack of assessment and management of the patient who pushed Mary over and this materially contributed to the incident occurring and therefore to Mary’s death.’ Section 4 of the Record of Inquest (which provided the conclusion as to Mary Pomeroy’s death) was determined, in narrative form, as: ‘Mary Pomeroy died from injuries suffered following being pushed over by a fellow patient on the same ward in hospital – this fellow patient had psychiatric, behavioural and cognitive difficulties and wasn’t being closely supervised on the ward.’ 5 CORONER’S CONCERNS During the course of the investigation and 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: Derriford Hospital in Plymouth is the main acute hospital site managed by UHP NHS. UHP NHS carried out a Root Cause Analysis (RCA) investigation in respect of the circumstances which led to Mary Pomeroy being pushed to the ground by a fellow patient on a ward at Derriford Hospital, Plymouth and her death thereafter. This investigation culminated in a written investigation report which was given executive sign off on 14 July 2022, by the SI panel chair and chief nurse of UHP NHS. The main body of the investigation report concluded that the incident which led to Mary Pomeroy being pushed to the ground by a fellow patient was ‘a rare and devastating accident for which could not have been foreseen’. The summary of the SI Panel Meeting Review, chaired by the Chief Nurse on 4 July 2022, stated that ‘overall it was considered that [the patient who pushed Mary Pomeroy] was managed appropriately during his admission to UHP NHS and concluded that this was a deeply unfortunate accident, but not one that could have been anticipated and therefore prevented by staff.’ The inquest heard evidence that the patient who pushed Mary Pomeroy to the ground on 3 March 2022 had done almost exactly the same thing to another patient on the ward only two days previously, on 1 March 2022 – this incident was discussed in the main body of the RCA investigation report, but not referred to at all in the SI Panel Meeting Review summary. The inquest also heard evidence that the patient who pushed Mary Pomeroy had been involved in a number of incidents where he had used physical force on staff members on the ward in February 2022. At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022. The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022. The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more. The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death. It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS, with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report. If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action (for the reasons set out in paragraph 5, above). 7 YOUR RESPONSE Your organisation is under a duty to respond to this report within 56 days of the date of this report, namely by 27 May 2025. I, the coroner, may extend this period. If any request is to be made for this period to be extended, please ensure this is made in writing at least 14 days prior to the above required response date. 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 Mary Pomeroy’s sons and the Care Quality Commission. I have also sent a copy of my report to the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. 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 Date: 1 April 2025 Signature: Nicholas Lane HM Area Coroner County of Devon, Plymouth and Torbay
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 Nurse & Director of Integrated Clinical Professions
Level 7, Derriford Hospital, Plymouth, Devon, PL6 8DH
Tel:
2nd May 2025
Mr Nicholas Lane
HM Area Coroner
County of Devon and Plymouth and Torbay
Dear Mr Lane
Re: Mary Margaret Pomeroy deceased – Regulation 28 Prevention of Future Deaths Report
I write in response to your Regulation 28 Report dated 01 April 2025 concerning the sad death of Mrs Mary
Margaret Pomeroy.
I would like to express our sincere condolences to Mrs Pomeroy’s family.
We have reviewed the concerns you have raised in the report regarding the investigation into the circumstances
surrounding the death of Mary Margaret Pomeroy, which was undertaken using the Serious Incident Framework,
as was mandated by NHS England at the time of the incident.
In June 2024, in line with other NHS Organisations across England, University Hospitals Plymouth NHS Trust
(UHP) transitioned to the use of the Patient Safety Incident Response Framework (PSIRF) and ceased the use
of the Serious Incident Framework (SIF).
The principles set out in the Patient Safety Incident Response Framework have fundamentally shifted the
approach to safety, and investigations into safety incidents within UHP. The PSIRF is not solely an investigation
framework but instead looks to support and develop a culture of transparency and learning, supporting the
development and maintenance of an effective patient safety incident response system. It incorporates x4 Key
Elements:
1. Compassionate engagement and involvement of those affected by patient safety incidents (patients,
families and staff)
2. Application of a range of system-based approaches to learning from patient safety incidents
3. Considered and proportionate responses to patient safety incidents
4. Supportive oversight focused on strengthening response system functioning and improvement
In support of the above elements, the Trust has taken the following actions:
1. Creation of a patient communication handbook
a. This is provided to patients and their families who are involved in safety incidents.
2. An information leaflet has been created for staff, outlining the purpose of the investigation, the process
that will be followed and signposting to support option.
3. The ongoing development of a Just and Restorative culture has been added to the Terms of Reference
for a Key Quality sub-committee (the Care Improvement Group)
a. Research indicates that barriers to transparency included fear, blame and shame. A just and
restorative culture is key to addressing this. By ensuring the ongoing development of such a
culture is included in the Terms of Reference for the Care Improvement Group, two elements are
achieved:
Working in partnership with the Peninsula Medical School
Chairman:
Chief Executive:
i. The delegated authority of the Safety, Quality, People and Culture Committee (a board
sub-group) to the Care Improvement Group ensures that the group has the authority to
undertake any actions as it deems necessary to promote a Just and Restorative Culture
ii. Regular update on progress in implementing this culture will be provided to the Safety,
Quality, people and Culture Committee, ensuring regular, board level oversight
4. Recruitment to x2 Learning Response Lead posts.
a. Both Learning Response Leads have completed mandatory training in compliance with national
guidelines set out in the Patient Safety Incident Response Framework. Whilst not a requirement,
both UHP Learning Response leads have backgrounds associated with the delivery of clinical
care (as a paramedic and a biomedical scientist) with professional registration.
b. These specialist investigators will undertake any Learning Response commissioned by the
Patient Safety Incident Response Group. In addition, these individuals will provide specialist
support and guidance in relation to other ongoing safety review processes (e.g. local Care Group
investigations).
c. The support of the Learning Response Leads will ensure that investigations within UHP move
away from Root causes Analysis (which has been shown to be ineffective) and towards a model
which supports understanding outcomes within complex socio-technical systems such as
healthcare..
5. Recruitment of two Patient Safety Partners. The remit of the Patient Safety Partner role is set out in the
National Patient Safety Strategy through the Framework for Involving Patients in Patient Safety. Patient
Safety Partners are lay people, who have extensive experience of receiving care and on occasion, may
have been involved in safety incidents. As such, they provide a different perspective on patient safety,
removing the potential of influence by organisational bias or historical systems.
a. The UHP Patient Safety Partners not only sit on key governance committees, but also support
investigation processes through the ongoing review and challenge of the investigation process
(during the investigation) and provide similar scrutiny to final reports.
6. Developed a new policy for the investigation of safety incidents, which includes new investigation methods
7. Redesigned our governance processes to further promote transparency and proactive multidisciplinary
review of quality concerns and undertaking assurance work on any actions implemented as a result of
those concerns. We have done this by ensuring:
a. Where investigations are commissioned, the Terms of Reference are agreed through a multi-
disciplinary approach and discussed with patients and families. As part of this process we would
consider any previous similar incidents and ensure key leads (this may be medical or nursing
leads, Allied Health Professionals, patient advocates, managerial support or any other key
personnel involved in the delivery of patient care) are involved in the investigation processes.
The investigation process University Hospitals Plymouth NHS Trust now follows is undertaken in accordance with
the Patient Safety Incident Response Plan and includes the following:
1. Patient safety incidents are recorded via a number of processes, including a healthcare safety incident,
patient concerns raised through a complaint or PALs. Staff concerns can also be raised as per the NHS
‘Freedom to Speak Up’ policy. On the identification of a concern, a DATIX is raised.
2. The concern is then raised at the Patient Safety Incident Response Group (‘PSIRG’), via a formal
escalation report (this meeting is chaired by the Trust Patient Safety Specialist and attended by a
multidisciplinary team that includes subject matter experts).
a. Concerns can be raised through any source, including incidents reported to Datix, patients, staff,
key external stakeholders, scrutiny of quality outputs or in response to key national reports and
findings.
3. The PSIRG commissions a review as follows:
Working in partnership with the Peninsula Medical School
Chairman:
Chief Executive:
a. There a number of different review options which are included in a separate file. The PSIRG will
collectively decide the most appropriate response type.
b. The terms of reference are agreed through a Multi-Disciplinary Discussion. These are discussed
with patients and loved ones to ensure they encompass any concerns they have
c. The review is assigned to a lead reviewer, who has the appropriate training and subject matter
expertise to undertake
4. The review is undertaken using a range of system-based approaches to learning keeping family and loved
ones involved as much as they wish.
5. A draft of the review is discussed at an “Open Door” event which is attended by a range of key
stakeholders, ensuring that all perspectives of the incident are discussed.
a. The draft is also shared with family and loved ones for their input.
b. Recommendations for improvement are agreed with all key stakeholders
6. The review outcomes and process are presented to the Care Delivery Group, a meeting chaired by either
the Head of Quality, Safety & Governance, or the Chief Nursing Officer and Chief Medical Officer as
required..
a. The Care Delivery Group (CDG) seeks assurance on the extent of the review process and
considers the appropriateness of the findings and agrees the recommendations made. In relation
to review outcomes, the CDG may:
i. Be assured on the review process and outcomes, agreeing with and endorsing the
recommendations
ii. Challenge any part of the review process or outcome.
iii. Commission further review where necessary (in cases where it is felt the review
presented was not robust enough, or did not capture the correct recommendations)
b. The recommendations are assigned to a key stakeholder to then develop specific actions to drive
improvement.
c. Assurances on the progress and implementation of recommendations is sought by the Care
Improvement Group, which is chaired by the Head of Quality, Safety & Governance.
I do hope that this detailed explanation provides you with the assurance that you require but please do not hesitate
to contact me if you should require any further information.
Yours sincerely
Chief Nursing Officer and Director of Integrated Clinical Professions
Working in partnership with the Peninsula Medical School
Chairman:
Chief Executive:
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