Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0445, written 2 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Sep 2025 |
|---|---|
| Reference | 2025-0445 |
| Deceased | Edward Funnell |
| Coroner | Andrew Morse |
| Coroner area | South Wales Wales |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW Telephone: 01443 281100 Email: Coroneradmin@rctcbc.gov.uk REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 2 3 The Chief Executive of Powys Teaching Hospital Board CORONER I am Andrew Morse, HMC for the Coroner Area of South Wales Central. 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. INVESTIGATION and INQUEST On 10 May 2023 I commenced an investigation into the death of Edward John FUNNELL. The investigation concluded at the end of the inquest 10/07/2025. The conclusion of the Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 inquest was Natural Causes. 1a Ischaemic left foot 1b Peripheral Vascular Disease 1c II Congestive Cardiac Failure, Chronic Kidney Disease, Ischaemic Heart Disease, Atrial Fibrilation CIRCUMSTANCES OF THE DEATH These were recorded as :- Mr Edward John Funnell died on 29th April 2023 at Ystradgynlais Community Hospital. Mr Funnell was admitted to Hereford Hospital on 16th December 2022 for an orthopaedic procedure. During his time at Hereford Hospital he developed a pressure ulcer on his left heel. Mr Funnell was not fit to be discharged home. He was transferred to Llanidloes War Memorial Hospital on 11th January 2023 until admission to Bronglais Hospital and transfer onwards to Morriston Hospital on 19th February 2023. During his time at Llanidloes the pressure ulcer worsened, and he developed an ischaemic left leg. On admission to Morriston Hospital he decided against surgery to amputate his ischaemic left leg and received palliative care at Ystradynlais Hospital from 24th February 2023 until his death. On balance it cannot be said that missed opportunities to treat and escalate the care of the worsening heel ulcer and signs of ischaemia in the left leg contributed to his death. 4 A finding of natural causes was made. During the course of the inquest extensive evidence was heard in respect of the wound dressings and interventions of nursing and Tissue Viability specialists during the deceased’s time at Bronglais Hospital. 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. 5 The MATTERS OF CONCERN are as follows. a. There was a lack of appreciation of the need for the deceased to see a podiatrist as recommended by a Tissue Viability Nurse. The referral was not followed up or actioned. b. There was an identifiable lack of knowledge on the part of the nursing staff to understand the reason for referral to a podiatrist and the possible interventions a Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 podiatrist could undertake in respect of pressure wound damage, particularly in patients with circulatory problems. c. There was an identifiable lack of knowledge on the importance of following the recommendations of the Tissue Viability Nurse in respect of the type of dressings to be administered and the importance of ensuring such steps were followed as opposed to using an alternative and, on the evidence, an inappropriate dressing. ACTION SHOULD BE TAKEN 6 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 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 28th October 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 family who may find it useful or of interest. 8 I am also under a duty to send the Chief Coroner a copy of your response. 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 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. 2 September 2025 SIGNED: Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 Andrew Morse HMC, South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
13 October 2025
Private and Confidential
Mr Andrew Morse
His Majesty’s Coroner
Dear Mr Morse
Re: Response to Regulation 28, following the death of Mr Edward
Funnell
This response is sent in accordance with your direction dated 2 September
2025 that a response from Powys Teaching Health Board (PTHB) is provided
to the Regulation 28 Prevention of Future Deaths Report, in the inquest
touching the death of Edward Funnell. This response seeks to explain the
actions to be taken to address the matters of concern and recommendations
as identified by the learned Coroner.
During the course of the inquest the evidence revealed matters that give rise
to concern, the matters of concern are outlined are as follows.
a) There was a lack of appreciation of the need for the deceased to see a
podiatrist as recommended by a Tissue Viability Nurse. The referral was
not followed up or actioned.
b) There was an identifiable lack of knowledge on the part of the nursing staff
to understand the reason for referral to a podiatrist and the possible
interventions a podiatrist could undertake, in respect of pressure wound
damage, particularly in patients with circulatory problems.
c) There was an identifiable lack of knowledge on the importance of following
the recommendations of the Tissue Viability Nurse in respect of the type of
dressings to be administered and the importance of ensuring such steps
were followed, as opposed to using an alternative and, on the evidence, an
inappropriate dressing.
Pencadlys
Tŷ Glasbury, Ysbyty Bronllys,
Aberhonddu, Powys LD3 0LY
Ffôn: 01874 712730
Cont….
Headquarters
Glasbury House, Bronllys Hospital
Brecon, Powys LD3 0LY
Tel: 01874 712730
Rydym yn croesawu gohebiaeth Gymraeg
Bwrdd Iechyd Addysgu Powys yw enw gweithredd Bwrdd Iechyd Lleol
Addysgu Powys
We welcome correspondence in Welsh
Powys Teaching Health Board is the operational name of
Powys Teaching Local Health Board
A response to each matter is provided below which will include actions taken
or action proposed to be taken within specific timescales.
a) There was a lack of appreciation of the need for the deceased to
see a podiatrist as recommended by a Tissue Viability Nurse. The
referral was not followed up or actioned.
Response
• We recognise that there was a delay of 27 days between the referral to
Podiatry and the initial appointment. During that delay, no follow up had
occurred to express the urgency of the referral.
Action
• The referral pathway to podiatry is being updated to ensure that urgent
referrals are responded to within 5 working days, if this is not possible an
escalation framework is in place to provide additional support.
• The Tissue Viability team have updated their referral process (Appendix
A) this has been shared widely with clinical teams, which underlines the
requirement for foot ulceration to be referred to Podiatry without delay.
(Implemented September 2025)
• Implementation of a Vascular limb check observation chart (Appendix B)
(Implemented September 2025)
• Learning identified within this Regulation 28 will be shared with all ward
leaders on 14 October 2025.
• 7minute briefing to be shared with all staff in the health board during
October 2025.
• Matters of the Regulation 28 and associated learning will be shared at the
Patient Experience, Quality & Safety Committee on 26 October 2025.
b) There was an identifiable lack of knowledge on the part of the
nursing staff to understand the reason for referral to a podiatrist and
the possible interventions a podiatrist could undertake, in respect of
pressure wound damage, particularly in patients with circulatory
problems.
Action
• Lead podiatrist to attend all wards to ensure the teams are aware of the
scope and breadth of the role of the podiatrist.
• Lead podiatrist to attend ward leaders meeting on 14 October 2025 to
ensure detailed scope and provision of service is understood.
• All pressure ulcers are monitored through All Wales Datix system and
presented through pressure ulcer scrutiny group. (Completed)
c) There was an identifiable lack of knowledge on the importance of
following the recommendations of the Tissue Viability Nurse in respect
of the type of dressings to be administered and the importance of
ensuring such steps were followed, as opposed to using an alternative
and, on the evidence, an inappropriate dressing.
Cont……..
2
Action
• Tissue Viability Specialist Nurse (TVN) to provide additional training to
ward teams regarding the use and access to dressings.
• Ensure all staff attend training provided by TVN’s which addresses
elements of assessment, escalation and dressing management.
Monitoring of these actions will be undertaken by the Community Service
Group Quality Meetings, supporting action plan is in included within Appendix
C.
I hope you can take assurance that the matters outlined within the Regulation
28 have been taken seriously and all associated actions will be undertaken in
a timely manner.
Should you require further clarity regarding the actions and attached action
plan please do not hesitate to contact my office.
Yours sincerely
Chief Executive Officer
Enc
3
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