Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0453, written 4 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 | 4 Sep 2025 |
|---|---|
| Reference | 2025-0453 |
| Deceased | Nicola Mulliss |
| Coroner | Thomas Crookes |
| Coroner area | Newcastle and North Tyneside |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Newcastle upon Tyne Hospitals 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.
Newcastle and North Tyneside Miss Georgina Nolan HM SENIOR CORONER Civic Centre , Barras Bridge , Newcastle Upon Tyne , NE1 8QH REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 4 September 2025 THIS REPORT IS BEING SENT TO: The Newcastle upon Tyne Hospitals NHS Foundation Trust CORONER 1 I am Thomas Crookes Assistant Coroner for the Coroner area of Newcastle and North Tyneside. 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. 2 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 20 February 2025 I commenced an investigation into the death of Nicola MULLISS. The investigation concluded at the end of the inquest. The conclusion of the inquest was that Nicola Mulliss died from natural causes and recognised complications of a necessary surgical procedure. The medical cause of death was; 3 1a Infarction of Brainstem and Cerebellum 1b Staphylococcal meningitis 1c Wound infection with Staphylococcus Aureus following surgical Re-Excision of Meningioma of Sphenoid Wing II CIRCUMSTANCES OF DEATH Nicola Mulliss had a history of recurring meningioma for which she underwent excision surgery in 2009 and 2011. On 29 January 2025 she had a further such procedure and initially made a good recovery. She experienced some leaking from the wound on 2 February 2025 and it was re-sutured. 4 Nicola Mulliss was re-admitted to hospital on 13 February 2025 and was found to have an infection to the operation site with staphylococcus aureus bacteria. This infection spread, resulting in staphylococcal meningitis which caused inflammation and swelling that disrupted the blood supply to her brain, leading to death on 18 February 2025. 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 – 5 In evidence I was told that had a swab been taken for microbiological analysis when the wound was re-sutured, it was possible that the Staphylococcus Aureus infection could have been detected at this earlier juncture and treatment instigated before the infection spread and resulted in the fatal staphylococcal meningitis. However, I was told that it is not policy / guidance for such testing to be undertaken so this did not occur. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you / your organisation have the power to take such action. 7 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 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 the Chief Coroner and to the following Interested Persons; (Mrs Mulliss' husband). 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. 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. 4 September 2025 9 Signature Tom Crookes Assistant Coroner for Newcastle and North Tyneside
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.
Headquarters
Freeman Hospital
High Heaton
Newcastle upon Tyne
NE7 7DN
30th October 2025
Mr Thomas Crooks
HM Assistant Coroner
Civic Centre
Barrass Bridge
Newcastle upon Tyne
NE1 8QH
Dear Mr Crooks
Thank you for your letter of 4th September 2025 following the inquest of NICOLA
MULLISS, in which you issued a regulation 28 report to prevent future deaths.
The matter of concern you identified was:
‘In evidence I was told that had a swab been taken for microbiological analysis when the
wound was re-sutured, it was possible that the Staphylococcus Aureus infection could
have been detected at this earlier juncture and treatment instigated before the infection
spread and resulted in the fatal staphylococcal meningitis. However, I was told that it is
not policy / guidance for such testing to be undertaken so this did not occur.’
Our response:
I would like to express our condolences to the family of Miss Mulliss. I am grateful for
your observations and we are committed to learning from this case to strengthen patient
safety and clinical practice.
Having reviewed your comments, we can confirm that it is not clinically appropriate to
take swabs of all leaking wounds. Wounds leak for a number of reasons, frequently as
a result of the natural healing process. Serous or haemoserous fluid leaks (as occurred
2
in this case) are common, and part of the inflammation associated with all wounds.
They are not indicative of infection. Like healthy skin, post operative wounds are
seldom sterile and microorganisms can be isolated from all wounds whether they are
infected or not. Isolating organisms does not always mean that the patient requires
antibiotic treatment and unnecessary use of antibiotics can lead to increased
antimicrobial resistance which is a global threat to health.
Staph aureus colonisation in the skin is common in the normal population, estimated to
be around 1 in 3 people, although this can vary in different age groups or health risk
factors. For certain procedures it is important to mitigate the risk of these and other
organisms from causing infection by ensuring asepsis of the surgical field, administering
prophylactic antibiotics among other measures. This is recognised by national and
international guidelines (NICE, WHO, CDC, and other professional bodies).
Following your correspondence, I can confirm that we will strengthen our pathways to
ensure that when a patient is suspected of having an infection, appropriate cultures are
undertaken in a timely manner, including wound swabs and that where clinically
appropriate, patients are commenced promptly on antibiotics. Compliance with these
standards is regularly monitored, and we will also consider additional ways to
strengthen these safeguards.
I hope this response reassures you that we are taking these issues very seriously and
are constantly seeking to further improve our standards in this important area.
Yours sincerely
Acting Chief Executive
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