Valerie Hampson

Chief Executive Officer 
 Tameside and Glossop Integrated Care NHS Foundation Trust  
Silver Springs  
Fountain Street  
Ashton under Lyne  
Lancashire OL6 9RW 

8th September 2025 

FAO Mr Morris 

HM Coroner  
Coroner’s Court  
1 Mount Tabor Street  
Stockport  
Cheshire  
SK1 3AG 

FURTHER INFORMATION, FOLLOWING THE INQUEST TOUCHING ON THE DEATH OF 
MRS VALERIE HAMPSON 

I am writing to you following the inquest touching on the death of Mrs Valerie Hampson, which 
concluded on 11th June 2025. 

Following  the  inquest,  you  raised  some  concerns  that  the  Trust  had  not  undertaken  any 
serious  incident  investigation  with  a  view  to  identifying  if  any  learning  could  usefully  be 
identified in the light of the progression of Mrs Hampson’s left leg wound whilst under the care 
of the District Nurses. It was a further matter of concern for you that the court heard evidence 
that  an  Orthopaedic  review  undertaken  in  the  Emergency  Department  on  Mrs  Hampson’s 
initial attendance resulted in a recommendation that Mrs Hampson should be followed up in 
fracture clinic. For reasons which did not become clear during the inquest, the evidence of the 
consultant orthopaedic surgeon was that no such follow up appears to have taken place. In 
order to address the concerns you raise, I have set them out below. 

CONCERN 1 

Mrs  Hampson  sustained  an  injury  to  her  knees  following  a  traumatic  fall  at  home  which 
prompted her attendance to the Trusts’ Emergency Department on 2nd October 2024. At the 
point of Mrs Hampson falling, she was not known to the District Nursing Service, however, 
had been intermittently know to the service since 2017.  

Mrs Hampson referred herself to the District Nursing Service on 4th October 2024. At that point 
the  injury  described  was  that  of  a  blister  to  her  right  knee,  therefore  the  damage  to  Mrs 
Hampson’s  knee  was  already  present  at  the  point  of  self-referral.  A  home  visit  was  then 
arranged for Mrs Hampson on 7th October 2024.  

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 The Queens Nursing Institute Workforce Standards for District Nursing state that registered 
nurse  visits  should  occur  on  every  fourth  visit  to  carry  out  the  nursing  process.  Whilst 
healthcare support  workers  and  nursing  associates can  be  involved  in  the nursing  process 
and  play  a  vital  role  in  the  delivery/implementation  of  care,  the  assessment,  planning  and 
evaluation of care remains the responsibility of the registered nurse.  

Mrs  Hampson  was  seen  by  a  combination  of  registered  nurses,  assistant  practitioners  and 
health care assistants and our local policy is for the registered nurse to attend every 3rd visit 
to ensure the care is led by a registrant. This is reflected and recorded in the attendance notes 
for Mrs Hampson.  

Mrs  Hampson’s  blister  remained  stable  for  several  weeks  until  29th  October  2024  when 
concerns were raised by another community healthcare team regarding the wound and Mrs 
Hampson was visited by a District Nurse Team Leader.  The wound was 60% granular and 
40% sloughy and measured 100mm wide by 75mm length and 1.5mm depth. The wound was 
photographed, cleansed and redressed and a referral was made to the Tissue Viability Team 
(TVN).  This  is  in  line  with  the  expectations  of  a  District  Nursing  role.  At  the  point  of 
deterioration, the Divisional Nurse Director was also made aware of this and she triggered an 
urgent Tissue Viability review following a review of the case.  

Mrs Hampson was then escalated to the Emergency Department on 30th October 2024 by a 
community practitioner and was reviewed by the Tissue Viability Nurses as an inpatient. She 
was  reviewed  by  the  surgical  team  and  referred  to  the  specialist  plastics  team  at 
Wythenshawe.  

Since the inquest we have revisit the care and treatment provided to Mrs Hampson. At the 
point the wound was noted to be deteriorating, Mrs Hampson was referred promptly back to 
the  Emergency  Department.  The  circumstances  surrounding  how  the  wound  occurred  and 
how it came to deteriorate did not fit the criteria for investigation in that: 

•  The wound was caused because of a traumatic injury following a fall which occurred 

whilst Mrs Hampson was not under the care of the District Nurses. 

•  Specialist opinion has been sought 
•  At the point the wound deteriorated it was promptly referred to TVN 

If the Trust were to be self-critical, a referral could have been made 24 hours earlier, however, 
that would not prompt any formal investigation, but it would contribute to local learning.  

Wound  care,  management  and  escalation  is  overseen  by  the  Divisional  Nurse  Director  for 
Integrated Tier Services. A meeting is held every Wednesday where pressure ulcers/moderate 
harm incidents are reviewed and advice provided. This was not considered a moderate harm 
incident.  

As  you  will  know,  the  Trust  moved  to  the  Patient  Safety  Incident  Response  Framework 
(PSIRF)  in  May  2024.  This  sets  out  the  NHS’s  approach  to  developing  and  maintaining 
effective system and processes for responding to patient safety incidents for the purpose of 
learning  and  improving  patient  safety.  This  governance  process  is  overseen  by  the  Chief 
Nurse and Medical Director. Whilst the Trust do not consider that an investigation was needed 
in this instance, I want to reaffirm that this process allows families and patients to share their 
perspectives and will formulate part of the investigation/learning response which we take very 
seriously.  

 
 
 
 
 
 
 
 
 
 The learning and outcome for Mrs Hampson in regards to the District Nursing Services has 
been shared at a local learning level since this inquest and at the weekly team meetings and 
escalation huddles which are held every day at 1pm. Within the last 12 months, the service 
has introduced a high impact board where details of complex patients’ needs are identified 
and shared. The service also participates in monthly Continuous Improvement Meetings (CIM) 
which enables lessons learnt and sharing to be cascaded across the Division. In addition, the 
Division  also  conduct  monthly  masterclass  sessions  by  the  Quality  and  Development 
Practitioner for the Intermediate Tier Services at the Trust. The masterclass sessions have a 
different theme each month based on previous incidents, safeguarding concerns or feedback 
from the coronial process. They are attended by all staff irrelevant of grade or role to ensure 
continued learning within practice.  

CONCERN 2 

As explained during the evidence, following Mrs Hampson’s first attendance to the Emergency 
Department  on  2nd  October  2024  an  x-ray  was  performed.  The  X-ray  did  not  identify  any 
fracture.  

On  a  further  review  of  the  Mrs  Hampson’s  records,  there  is  no  appointment  that  has  been 
arranged for the out-patient fracture clinic. The discharge documentation states no mention of 
fracture  clinic  appointment.  The  follow  up  was  that  once  discharged,  care  would  continue 
under the District Nursing Service. Following Mrs Hampson’s attendance on 30th October 2024 
she  was  admitted  and  referred to  Wythenshawe  and  she  was managed as an  in-patient  in 
Tameside Hospital until she could be transferred to Wythenshawe on 1st November 2024. I 
am sorry that this information was not made clear to you during the inquest. I can confirm that 
there was no follow up appointment made in the fracture clinic for Mrs Hampson as no fracture 
was identified.  

I do hope that this letter provides you with further reassurance following the inquest, however, 
should you have any queries arising from the content of this letter or require further information 
or  clarification,  please  do  not  hesitate  to  contact  Legal  Services 

Yours sincerely,  

Medical Director 
On behalf of 
Tameside and Glossop Integrated Care NHS Foundation Trust 

(Chief Executive Officer)