Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0343, written 7 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2025 |
|---|---|
| Reference | 2025-0343 |
| Deceased | Patrick Coffey |
| Coroner | Robert Simpson |
| Coroner area | Berkshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Frimley Health 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 CEO - Frimley Health NHS Foundation Trust 1 CORONER I am Robert SIMPSON, Assistant Coroner for the coroner area of Berkshire 2 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. 3 INVESTIGATION and INQUEST On 01 October 2024 I commenced an investigation into the death of Patrick Anthony COFFEY aged 85. The investigation concluded at the end of the inquest on 06 June 2025. The conclusion of the inquest was that: On the 29th September 2024 Patrick Anthony Coffey died at Wexham Park Hospital, Slough. He fell at home on the 12th September fracturing multiple ribs and remained on the floor until the following day contracting a chest infection. He was admitted to hospital for treatment but continued to deteriorate. 4 CIRCUMSTANCES OF THE DEATH As a result of falling at home Mr Coffey fractured multiple ribs and remained on the floor for about 17 hours. On arrival at hospital he was found to have contracted a chest infection. He suffered from COPD which did not usually affect his life and he was mobile prior to the fall. He was assessed in hospital and it was decided to treat the fractures conservatively. This required effective pain control which was not always offered or achieved. He did undergo 2 periods of local anaethesia infusions which were more effective in controlling the pain. He was treated with anitbiotics for the chest infection throughout his stay. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures. The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either nor being done or not being properly recorded for some patients. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis. Of particular note is the following: 1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24, 2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24 3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24 4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11 5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24 6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24 7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03. These records therefore have gaps of up to 27 hours. In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded. The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by September 01, 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mr Coffey I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Dated: 07/07/2025 Robert SIMPSON Assistant Coroner for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Frimley Park Hospital Portsmouth Road Frimley Surrey GU16 7UJ 0300 614 5000 www.frimleyhealth.nhs.uk 1st September 2025 HM Coroner Mr Robert Simpson Assistant Coroner for Berkshire Berkshire Coroners’ Office Reading Town Hall Blagrave Street Reading RG1 1QH Dear Mr Simpson REF: YOUR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS DATED 07 JULY 2025 I write further and in response to the Regulation 28 Report received on 07 July 2025, following the sad death of Mr Patrick Coffey on 29 September 2024. My deepest sympathies go out to Mr Coffey’s family and those who knew him. I am grateful for your thorough inquest into Mr Coffey’s death. I would like to take this opportunity to reassure you that patient safety is taken very seriously by the Trust, and the Trust is committed to review and reflect on current practices to identify areas of improvement. I have carefully considered your observations, and the recommendations raised in your Regulation 28 Report to ensure that patients receive the best quality care at the Trust and that future deaths are prevented. Matter of Concern 1: Repositioning Protocols The Trust has an established Pressure Injury Reduction improvement work stream which is being led by the Corporate Head of Nursing as the Senior Responsible Officer which includes the clinical importance of repositioning for patients at risk of respiratory compromise and pressure injury. At the time of Mr Coffey’s admission, repositioning protocols were supported by Waterlow assessments and physiotherapy documentation including repositioning records as part of the daily care plans within the Electronic Patient Record. The improvement work stream is focussing on implementing a number of changes which will improve care and documentation across the Trust relating to repositioning and the prevention of pressure damage including the following: From 1 September 2025, the Na(cid:415)onal Pressure Injury Screening Tool, Purpose T, will be implemented across adult inpa(cid:415)ent and emergency departments, with maternity and paediatrics to follow later in December 2025. Through this period of change, the Trust will adopt the na(cid:415)onally recommended ulcer categories and care pathways, alongside a review of data valida(cid:415)on processes. The Nursing, Midwifery and Therapies Board, will be monitoring the progress and the governance processes with escala(cid:415)on through established documenta(cid:415)on and digital safety groups, and in due course a Trust-wide audit will be planned, with re-audi(cid:415)ng scheduled to provide internal assurance. While Purpose T recommends reposi(cid:415)oning, it does not prompt it directly. Accordingly, we have worked with our electronic pa(cid:415)ent record (“EPR”) supplier EPIC to introduce task prompts at defined intervals, visible on the care plan interface to support compliance (as below). This work forms part of a broader pressure ulcer improvement programme aligned with the Na(cid:415)onal Wound Care Strategy. This Pressure Ulcer Improvement Programme is recognised as part of the Trust’s Pa(cid:415)ent Safety Incident Response Framework (“PSIRF”) Plan and is a Trust Quality Improvement Priority for 2025–26. Awareness will be further supported through par(cid:415)cipa(cid:415)on in na(cid:415)onal ini(cid:415)a(cid:415)ves such as Stop the Pressure Week in November 2025. The improvement work stream has been monitoring data as part of its Quality Improvement Methodology and for Quarter 1 2025/26 performance has significantly improved particularly for Category 2 pressure injuries with a 52% reduction compared to the same quarter last year. Matter of Concern 2: Staff Training and Awareness To support clinical teams, we have introduced system-driven prompts within the EPR that will automatically trigger repositioning tasks when patient pathways are documented. These appear on the care plan interface to ensure integration into routine workflows. For clarity, this prompt will not be recorded in the printed patient records, rather it will appear as an alert on screen for staff to take action. These prompts will be auditable on a ward and patient level, with staff able to pull through repositioning information onto a dashboard for reporting and auditing purposes. The Trust has also launched a targeted staff communication campaign, including the distribution of an EPR Bulletin to all relevant clinical teams, these are regularly shared to highlight key educational messages to staff. I understand that the Bulletin reinforcing the importance of timely and accurate documentation of patient repositioning was shared with your office in early July. To further support staff, the Trust has expanded our Digital Ambassadors Network, providing peer-to-peer training and access to ‘training buddies’ who can assist with EPR-related queries and reinforce best practice. Education sessions have also been delivered, and in addition the Trust Clinical Education and Practice Development Teams have been visited wards to support staff in practice with documentation of repositioning, risk assessments and using EPIC effectively. A formal Harm Free Care Audit Programme is in place (commenced July 2025). The pressure injury prevention sections tests out whether assessments have been done in a timely manner and whether the appropriate care interventions such as repositioning have been put in place. The audit in July 25 showed a 20% improvement in the documentation of the interventions from a previous audit (60% to 80%) compliance. Matter of Concern 3: Electronic Patient Record Your concern about the clarity and completeness of EPRs, particularly in relation to the documentation of patient repositioning, has been noted. We recognise the importance of ensuring that clinical records are both accurate and accessible, especially when reviewed in the context of coronial investigations. The Trust acknowledges that the version of the records disclosed to the Court differ in appearance from the user-interface that staff access, which can be challenging at inquests. To address this, the Trust is working directly with EPIC National Team to review the current output documents provided to Coroners. The objective of this review is to enhance the clarity, structure, and usability of these records, ensuring they support the coroner’s review process effectively. In parallel, we are engaging in a collaborative learning initiative with the wider EPIC user network to understand common challenges in presenting electronic clinical notes ‘off system’ and identifying best practices to be adopted locally. Further, the Trust remain open to meet with the Senior Coroner for Berkshire to discuss this matter further. I hope that my response highlights the steps that the Trust has and will continue to take to improve the patient safety at the Trust, in particular repositioning which falls under the Pressure Injury Reduction improvement work stream. An improvement plan based on learning from this inquest, to include the actions above, will be created and actioned with monitoring by the appropriate clinical governance teams within the Trust. The Trust appreciates your thorough investigation and challenge, both of which are essential so that the Trust can continue to learn lessons and take steps to improve patient safety and the quality of care we provide our patients. As ever, my thoughts remain with Mr Coffey’s family and all those affected by his very sad death. Yours sincerely Chief Executive
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