Mary Fitzpatrick

Record of Inquest 

Following  an  inquest  opened  on 27  March  2025  and  an  inquest  hearing  at St  Pancras  Coroner's  Court  on 
the Nineteenth of August 2025, heard before Coroner IE Potter in the area of HM Coroner for Inner North London, the 
following is the record of the inquest (including the statutory determination and, where required, findings). 

1.  Name of deceased (if known): 

            Mary Anne FITZPATRICK    

2.  Medical cause of death: 

      1a    aspiration pneumonia         
      1b    dysphagia         
      1c    frailty         
      1d              
       2     sacral pressure sore 

3.  How, when, where and, for investigations where section 5(2) of the Coroners and Justice Act 2009 applies in 

what circumstances, the deceased came by his or her death (see note (ii)): 

        4.  Conclusions of HM Coroner or the jury as to the death (see notes (i) and (ii)): 

             Mary Fitzpatrick was sent to a hospital emergency department on 23 January 2025 not 
for any medical indication, but because a district nurse did not have a colleague to assist with 
wheelchair  to  bed  transfer  and  believed  that  she  could  not  manage  her  patient's  transfer 
alone, though solo transfer had been effected several times before.  Mrs Fitzpatrick waited on 
a hospital trolley for some hours for treatment and a sacral pressure sore developed. She was 
2025.  
discharged 
On  1  February  2025,  the  sacral  pressure  sore  was  noted  to  be  a  category  2.   The  district 
nursing service failed to attend her to change the dressing with appropriate frequency and, by 
24 February the sore had deteriorated to a category 4.  As a consequence, Mrs Fitzpatrick had 
to be re-admitted to hospital on 27 February, where she deconditioned and eventually died on 
2025.  
20 
Death was the result of natural causes.  However, it would not have occurred when it did, had 
it not been for the 23 January admission to hospital, the development of the sacral pressure 
sore, and the failure appropriately to treat that pressure sore. 

January 

March 

home 

on 

29 

5.  Further particulars required by the Births and Deaths Registration Act 1953 to be registered concerning the 

death:  
 (a)  Date and place of birth 
         Second of December 1938  
         Dublin, Ireland 
 (b)  Name and surname of deceased 
         Mary Anne FITZPATRICK 
 (c)  Sex 
         Female 
 (e)  Date and place of death 
        Twentieth of March 2025 
        University College Hospital, 235 Euston Road, Bloomsbury, London 
 (f)  Occupation and usual address 
        carer (retired) widow of John Patrick Fitzpatrick, Butcher 
        Flat 1, Forrest Court, 4 Ellington Street, London 

 (d) Maiden surname of woman who has married 
       Rooney 

 
            
  
  
   Signature of Coroner ME Hassell, HM Senior Coroner

Chief Medical Officer 
Deputy Chief Executive 
Medical Directorate 
Jenner Building 
Magdala Avenue 
London N19 5NF 

20/10/25 

To: 
Senior Coroner ME Hassell 
Inner North London Coroner’s Court 

Response to Regulation 28: Prevention of Future Deaths Report 

Re: Mary Anne Fitzpatrick (died 20 March 2025) 

Dear Senior Coroner Hassell, 

Thank you for your Regulation 28 report dated 20 August 2025 concerning the very 
sad death of Mrs Mary Fitzpatrick. On behalf of Whittington Health NHS Trust, I wish 
again to express our condolences to her family. 

We take the concerns you have raised extremely seriously. This response sets out 
the actions we have already taken and those we are committed to undertaking to 
ensure learning, improvement, and prevention of similar future deaths. 

1. Circumstances of Hospital Admission and Risk of Deconditioning 

We recognise the risks associated with hospital admission for frail elderly patients, 
particularly where transfer occurs due to staffing limitations in community settings. 

We accept that in this instance, the care of Mrs Fitzpatrick fell short in a number of 
ways. 

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 •  Missed leg ulcer management: On the balance of 

probabilities, the deterioration of her leg ulcers was linked to the lack of 
treatment following the cancellations of scheduled appointments on 18, 20, 
21, and 22 January 2025. As there was no evidence of mental impairment at 
that time, a mental capacity assessment was not carried out with regards to 
the decision to cancel visits, and she was presumed to have capacity. 

•  Time in the Emergency Department: Mrs Fitzpatrick spent 40 hours in the 

Emergency Department, due to the department being under extreme 
pressure. some of this time in a temporary escalation space. We accept this 
falls short of the standard of care we would aspire to provide. Mrs Fitzpatrick 
arrived in Triage at 20:27. She was then transferred to a trolley and initially 
cared for in a temporary escalation space. While we work to avoid care in 
temporary escalation spaces, we have a standard operating procedure to set 
out the care which should carry on in non-clinical areas when necessary. At 
23.45 Mrs Fitzpatrick was moved into a cubicle in the Majors area. She was 
transferred to a bed at 03:33 on 24/01/25.  She was placed on a standard 
foam pressure relieving mattress at this time. When she was moved to the 
ward she was placed on a pneumatic pressure relieving mattress.   

•  Pressure sore identification and management: Her pressure areas were 
reviewed and documented within 2 hours of arrival and this identified her 
pressure sore. She was subsequently admitted and had further reviews, and  
the correct equipment and care plans were instituted. 

•  Risk factors: The risk of pressure sores was increased due to Mrs 

Fitzpatrick’s frailty and incontinence. We regret that she developed additional 
grade 2 sores during her hospital admission. 

Action Plan: 

A Quality improvement Project is in progress in our ED to monitor adherence to 
Pressure Ulcer Prevention and Management Policy as ED acknowledge that elderly 
patients spend longer in ED due to the complexity of their care. The standard is that 
all at risk patients will have their pressure areas reviewed within one hour of 
admission, and that prevention management will be instituted within four hours. The 
project is carrying out spot check audits of a 10-point check list for 10 patients per 
week. The results will be presented to will be presented Emergency and Integrated 
Medicine Quality Committee on 20th November 2025. 

Our Trust Policy governing care in temporary escalation spaces has been appended 
for reference.  

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
 
 
 2. Frequency and Quality of District Nursing Visits 

We acknowledge the coroner’s concern regarding the frequency and 
appropriateness of district nursing visits and dressing changes. A review of Mrs 
Fitzpatrick’s records has allowed us to reconstruct the chronology of community 
nursing input following her hospital discharge: 

•  There were 2 missed opportunities for dressing changes on 5 February (visit 
not allocated) and 10 February (Mrs Fitzpatrick declined to be moved by the 
two staff members attending so dressings were not completed). 

•  Despite these missed visits, there was regular documentation of wound 

progression, escalation to the GP, referral to Tissue Viability, and repeated 
advice regarding hospital admission.  

•  When the pressure ulcers were found to have deteriorated. A Safeguarding 
Alert was raised as the pressure relieving mattress had been found to be 
switched off with no explanation on 24 February 2025. 

•  Staffing during this period was affected by long-term sickness (1 staff member 
>4 months) and annual leave (2 staff members). However agency and bank 
nurses were used to maintain service cover, and a bank nurse undertook the 
joint visit on 8 February. 

•  Double-handed visits were provided where identified as necessary from 7 

February onwards. 

•  We apologise that this information was not fully accessible to the coroner 

during the inquest  

Action Plan: 

•  Ensure daily visits allocations are individualised to meet the patients’ Pressure 
Ulcer (PU) management need by the duty manager, with monthly oversight 
from Service Lead. 

•  Timely referral to Tissue Viability Nurse (TVN), adherence with TVN 
recommendations, and progression of pressure ulcer management 
improvement plan are to be built into new quarterly audit cycle, and reviewed 
at divisional quality meeting. 

•  Shared learning from PU incidents will be ensured via weekly divisional 

pressure ulcer shared learning meetings.  

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 
 •  A trial of visit allocation software (Docabode) is in 

progress in the Urgent response team and is intended to minimise travel time 
and maximise time for visits. If successful it will be trialled in District Nursing  

3. Reflection, Learning, and Preparation for Inquests 

We acknowledge the coroner’s concern that there was insufficient reflection on the 
quality of district nursing care provided to Mrs Fitzpatrick, both during her 
deterioration and in preparation for the inquest. We accept that the deputy manager 
who attended court was not adequately prepared to give evidence, which fell below 
the expected standard.  

We also recognise that our communication with Mrs Fitzpatrick’s family—both in 
person and in writing—did not provide the clarity, explanation, or candour they 
deserved, and that this contributed to their distress. 

Action Plan: 

Mortality review process: Current mortality review processes are largely designed 
to cover inpatients. New procedures are being devised to ensure all patient deaths 
under our care in the community services we run are formally reviewed for learning.  

Learning from Death: incidents and feedback, inquest outcomes and PFD notices 
will continue to be shared with staff at meetings. In addition, they will also be 
cascaded to all staff working in community services. 

Increase in support and training for staff involved in writing statements and 
attending the coroner’s court: This will also include advice to ensure that staff will 
not only cover the care that was delivered by themselves, but provide an overarching 
statement covering the care delivered as a whole by the Trust. Support will be given 
by the legal services team. The Trust is reviewing the seniority of staff attending 
coroner’s court to provide the court with the most useful and informative evidence. In 
addition to this, new guidance for staff preparing for inquests will be circulated by the 
Associate Medical Director for learning from deaths, in coordination with the legal 
department. 

New proforma: A new Duty of Candour proforma has been developed to accurately 
capture both professional and written Duty of Candour, ensuring documentation is 
clear and complete. This will better enable tracking and audit of statutory duty of 
candour across the trust. We expect to have this completed by December 2025, with 
the results presented to the Quality Governance Committee. 

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
 
 
 
 Duty of Candour audit and training: Ongoing audit and 
refresher training are being introduced to strengthen understanding of and 
compliance with Duty of Candour. Levels of completion of training will be monitored 
by the patient safety team, and the results presented to the Quality Governance 
Committee quarterly. 

Chief Medical Officer  

Whittington Health NHS Trust 

Helping local people live longer healthier lives