Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0327, written 27 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2025 |
|---|---|
| Reference | 2025-0327 |
| Deceased | Brenda Fisher |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Stockport NHS Foundation 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care
CORONER
I am Chris Morris, Area Coroner for Greater Manchester (South).
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 20th February 2025, an inquest was opened into the death of Brenda Fisher who died at Stepping
Hill Hospital, Stockport on 16th January 2025, aged 86 years. The investigation concluded with an
inquest which I heard on 23rd June 2025.
The inquest heard evidence that Mrs Fisher died as a consequence of:
1)a) Pseudomonas aeruginosa sepsis;
b) Cellulitis from leg ulcers;
II Rhabdomyolysis following long lie; heart failure
At the end of the inquest, I recorded a conclusion of Accident.
CIRCUMSTANCES OF THE DEATH
Mrs Fisher died on 16th January 2025 at Stepping Hill Hospital, Stockport as a consequence of
complications arising from wounds initially sustained in a minor accident at home which would not
heal as a result of her complex underlying health problems. Mrs Fisher's death was contributed to by
Rhabdomyolysis.
CORONER’S CONCERNS
During the course of the 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. –
The court heard evidence that on her final attendance to hospital, Mrs Fisher was cared for in the
Emergency Department’s ‘Rapid Assessment and Triage’ Corridor for at least 23 hours before a bed
was found for her.
Whilst the Trust has undertaken a number of steps locally to mitigate the risks associated with this
practice, I am concerned that there remains a residual and inherent risk of death arising from
patients remaining for lengthy periods in areas not designed or intended for undertaking
observations and providing care.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
22nd August 2025. I, the coroner, may extend the period.
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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner, together with the family and Stockport NHS
Foundation Trust.
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.
Dated:
27th June 2025
Signature: Chris Morris, Area Coroner, Manchester South.
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.
Karin Smyth MP Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU Our ref: PFD – 25-06-27 – FISHER HM Coroner Chris Morris Coroner’s Court, 1 Mount Tabor Street, Stockport, SK1 3AG By email: manchestersouthcoroners@stockport.gov.uk 22nd August 2025 Dear Mr Morris, Thank you for the Regulation 28 report of 27 June sent to the Secretary of State about the death of Brenda Fisher. I am replying as the Minister with responsibility for urgent and emergency care. First, I would like to say how saddened I was to read of the circumstances of Mrs Fisher’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns regarding prolonged A&E waits, corridor care and operational pressures faced by Stockport NHS Foundation Trust. I understand that you have also sent a copy of your report directly to the trust who is best placed to respond on the specific actions undertaken locally in response to the concerns you raise. However, in preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that Stockport NHS Foundation Trust has recently opened its new Emergency and Urgent Care Campus, providing extra clinical space in the Emergency Department (ED) to reduce congestion. This also provides additional escalation areas to help avoid corridor use. The trust has updated its escalation plans in line with the new space, with agreed areas designated as the default alternative to corridors. In the event of any patients unavoidably needing to be cared for in a corridor, an agreed Standard Operating Procedure is in place at the trust to ensure that the best care possible is delivered in these circumstances. The trust has also established a transformation programme aimed to improve the wait time patients experience in the ED. This programme includes work regarding long waiting patients and improved navigation and triage. The trust’s capacity protocol plan aims to maintain patient safety and smooth operations by moving patients to designated, fully staffed escalation areas when the hospital is full, easing pressure on high-risk areas like A&E, improving flow, and ensuring timely care with extra support, rapid discharge, and close monitoring. I am pleased to note that the trust has seen an improvement in A&E patients admitted, transferred or discharged within 4 hours (74.0% in June compared to 65.4% in May) and for patients who waited in the department for more than 12 hours from arrival (6.1% in June compared to 12.5% in May). However, the Government accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. At a national level, NHS England has published Principles for providing safe and good quality care in temporary escalation spaces (TES’s) to guide NHS providers in maintaining high-quality care in these environments. Guidance specific to corridor care will be released later this year. NHS England has been working with trusts since 2024 to put in place new reporting arrangements related to the use of TES’s, to drive improvement. Subject to a review of data quality, this information will be published soon, and we will consider how this data could be published on a more regular basis. In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting. In July 2025, we published the Ten Year Health Plan to create a new model of care, fit for the future. A key focus of our approach will be to expand access to urgent care services at home and in the community as part of our new Neighbourhood Health model. This will improve the experience and care that people receive, rather than having to go to hospital unnecessarily. This will reduce demand in ED’s, meaning that they are liberated to focus on providing the best, most cutting-edge and most productive care for those who most need it. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, KARIN SMYTH MINISTER OF STATE FOR HEALTH
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