Iris Carter

10th June 2025  

STRICTLY PRIVATE AND CONFIDENTIAL 
ADDRESSEE ONLY 

For the attention of Mr Brenchley 
Assistant Coroner for Birmingham and Solihull 

Sent by way of email only: 

Dear Mr Brenchley 

Inquest touching the death of Iris Carter 
Response to Regulation 28 Report to prevent future deaths 

I  am  writing  in response  to the  Regulation  28  notice issued following  the  conclusion  of the 
Inquest on 10 April 2025 touching the death of Mrs Carter who died on 8 November 2024 at 
Birmingham  Heartlands Hospital  (part  of  University  Hospitals  Birmingham  NHS  Foundation 
Trust (UHB)).  

We have carefully considered the concerns raised within your report to prevent future deaths 
and would respond as follows. 

Matters of concern highlighted: 

1.  On her arrival at the Ann Marie Howes  Rehabilitation Unit on 27th March 2024 
Iris was assessed and found to have a Grade 4 Pressure Sore on her left heel 
which I was satisfied must have been present prior to her discharge the same 
day from the Queen Elizabeth Hospital. 

Mrs Carter was discharged from ward 410 on 27th October 2024 and subsequently admitted 
to Ann Marie Howes for ongoing rehabilitation.    

The ward described the patient’s skin as having a “blister is present to heel” in the morning 
nursing  care  plan  before  she  left  for  transfer  to  Ann  Marie  Howes  Centre.    There  is  no 
documentation outlining any nurse-to-nurse handover, neither what was discussed regarding 
Mrs  Carter’s  pressure  areas.    We  would  like  to  apologise  for  this  and  can  confirm  that  the 
presence of a pressure area was highlighted in the nurse discharge noting.  The Standardised 
Transfer of Care Document (STOC) did include the level of pressure damage and identified 
the area on Mrs Carter’s skin. The team at Ann Marie Howes would have been in receipt of 
this document, prior to the agreement to transfer Mrs Carter into their care. 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Mrs Carter’s skin was first noted to have pressure related damage on 15th October 2024 and 
this was documented as being a Deep Tissue Injury (DTI).   

A  DTI  is  defined  within  the  Queen  Elizabeth  Hospital  Birmingham,  in  accordance  with 
nationally recognise guidelines, as – 

Intact  or  non-intact  purple/maroon  area  of  discolouration  or  blood-filled  blister.  Pain  and 
temperature change often precede skin colour changes. Discolouration may appear differently 
in darker pigmented skin. Evolution may be rapid exposing additional layers of tissue even 
with optimal treatment or may resolve without tissue loss. 

An  incident  form  was  completed  on  15th  October  2024,  the  categorisation  of  the  level  of 
pressure  was  verified  by  2  nurses  –  1  sister  and  1  senior  sister.    It  was  described  in 
appearance as a blood-filled blister to the heel. 

2.  I heard evidence during the inquest that Iris was at heightened risk of developing 
pressure  sores  given  her  co-morbidities  and  reduced  mobility  post  her 
operation and that a Grade 4 pressure sore is the most serious type of pressure 
sore where bone is exposed and can therefore be at risk of infection. 

We can confirm that the Waterlow score, and other care assessments were completed within 
6 hours of Mrs Carter’s admission. 

Mrs  Carter’s  risk  factors  were  recognised,  with  a  consistent  Waterlow  score  during  her 
admission of being above 25.  

Equipment selection:  

Following identification of a high Waterlow score, the mattress was incorrectly documented as 
soft  foam,  however  documentation  in  the  clinical  noting,  entered  by  a  physiotherapist  on 
multiple occasions, identified it as an air mattress – specifically documenting that the patient 
was struggling  to mobilise from  the  mattress,  due  to the movements  from the  air changing 
cycles. 

Repositioning: 

The  repositioning  plan,  outlining  a  4  hourly  regime,  was  consistently  recommended  in  Mrs 
Carter’s care plan and was commenced from  the point of  admission, but we recognise this 
should have increased to a 2 hourly monitoring regime since the development of DTI. 

Following  a  review  of  the  documentation,  it  was  highlighted  that there  were  inconsistences 
with the 4 hourly repositioning, and a summary of the findings are as below: 

Mrs Carter was not able to tolerate  positional changes, and this is documented on multiple 
occasions. This was because of pain experienced as a result of her surgery and chronic pain 
experienced from a previous amputation, which in itself would have increased her risk factors.   

Non  concordance  documentation  was  not  completed  when  repositioning  was  refused, 
however is clearly documented throughout the nursing noting.   

This lack of positional change would have further increased the risk to Mrs Carter.    

 
 There  was  documentation  to  support  the  use  of  heel  off-loading  devices  and  further 
documentation  specifying  the  use  of  pillows.    Ms  Carter  was  reviewed  daily  as  part  of  her 
repositioning  plan,  which  outlined  4  hourly  repositioning.      The  skin  inspection  charts  were 
completed daily; however, the charts were not fully completed. 

The Waterlow assessment was reassessed weekly as per policy – this showed a consistently 
high Waterlow score of above 25 on every assessment.  

3.  However,  apart  from  one  entry  on  13th  October  2024  in  the  QEH  electronic  in 
patient noting records when it was recorded that Iris was complaining of pain 
on palpation of her left heel and a pillow was placed under her heel, there is no 
reference  in  the  noting  to  it  having  been  observed  at  any  point  that  Iris  had 
developed a pressure sore to her left heel during her admission at the QEH. 
4.  This leads to a concern that either the skin to her left heel was not being properly 
inspected  or  if  it  was  that  such  inspections  were  not  adequately  noted  in the 
electronic in-patient noting. 

Our  review  of  the  documentation  outlined  in  the  medical  noting  documents  there  was  no 
pressure damage noted on 09.10.24 at 14:18 by the Ortho geriatrician team, who noted review 
of the lower limb and noted oedema present to Mrs Carter’s leg. 

Following the medical review on 11.10.24 no pressure damage was noted by the Trauma and 
Orthopaedic  (T&O)  doctors,  but  an  assessment  was  carried  out,  due  to  Mrs  Carter 
complaining of pain in her lower limb. 

On 12.10.24 T&O doctors assessed Mrs Carter’s toes, due to complaints of neuropathy and 
lack of movement of the toes.  There was no documentation to suggest pressure damage was 
observed. 

On 13.10.24 T&O Doctors assessed Mrs Carter’s heel and palpated the heel.  There was no 
documented evidence of pressure damage at this time. 

There was no record of pressure damage noted in the daily nursing care plan or repositioning 
regime  until  the  15.10.24.    It  was  then  documented  that  a  health  care  assistant  found  a 
suspicious blister whilst providing personal care to Mrs Carter.  This was then documented 
and escalated to the registered nurse caring for Mrs Carter.   The blister was assessed and 
verified as being a Deep Tissue Injury by 2 qualified nurses (a junior sister and senior sister) 
and an incident report was submitted, which clearly indicated the appearance of a blood-filled 
blister, with the care plans then being updated to reflect this. 

Upon  readmission  to  Birmingham  Heartlands  Hospital  on  06.11.24  the  pressure  area  was 
recorded  as  being  unstageable,  defined  within  the  Queen  Elizabeth  Hospital  Birmingham 
guidelines, in accordance with nationally recognise guidelines as – 

 
 
 
 
 Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough 
or  necrosis.  Until  enough  slough  and/or  necrosis  are  removed  to  expose  the  base  of  the 
wound, true depth cannot be determined, but it will be Category 3 or 4. Stable (dry, adherent, 
intact without erythema) eschar/necrosis on the heels serves as ‘the body’s natural (biological) 
cover’ and should not be removed 

Assurance: 

While reviewing the incident in November 2024, the omissions in producing appropriate and 
accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted.  In 
response to these findings, the senior sister and her team highlighted the omission in care to 
the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention 
strategy  within  the  Trust.   The  actions taken  at  the  time  were  to  update the  pressure  ulcer 
prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily 
safety huddle on the ward.  Another change in practice is that the nurse in charge of each shift 
will  carry  out  a  safety  check,  ensuring  all  care  assessments,  specifically  the  patient  skin 
inspection charts, are fully completed. The senior sister has also been completing spot checks 
since December 2024. 

Tissue Viability Response: 

The  Tissue  Viability  Team  (TV)  receive  a  daily  pressure  ulcer  report  from  Radar  (system 
managing incident reports), which will inform their clinical workload for the day. Radar forms 
for patients who are reported as having trust acquired deep tissue injury (DTI), unstageable, 
category 3 or category 4 pressure ulcers are manually added to the Priority 1 section of the 
clinical referral excel spreadsheet. Radar is the clinical incident reporting system used at UHB. 
It appears that when Radar SE-18198, (the Radar form outlining the DTI to the left heel which 
was Trust acquired), was added to the TV clinical referral sheet it was incorrectly documented 
as  being  non-Trust  acquired.  Therefore,  it  was  not  placed  in  the  Priority  1  section  of  the 
spreadsheet  and  Mrs  Carter  was  not  seen  by  TV  during  her  QEHB  admission.  However, 
pressure ulcer prevention strategies were initiated from the point of admission.  

Assurance: 
The findings will be shared at June 2025 Tissue Viability Team meeting. Tissue Viability and 
the Radar team have liaised to produce a daily Radar report that more readily identifies Trust 
and non-Trust acquired pressure ulcers.  An audit of manual transfer of data from daily Radar 
report to clinical referrals spreadsheet is in progress. The electronic transfer of data from the 
daily Radar report to the clinical referrals sheet is currently being explored.  

I would like to assure you that the concerns raised within the Regulation 28 Report have been 
taken extremely seriously, which I hope is demonstrated in the steps that have been taken 
following Mrs Carter’s death. 

Yours sincerely 

, Chief Executive Officer