Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0462, written 10 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 | 10 Sep 2025 |
|---|---|
| Reference | 2025-0462 |
| Deceased | Walter Horton |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Care Home Health related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching 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.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER’S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Date: 10 September 2025 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 THIS REPORT IS BEING SENT TO: Mr Nick Mallaband , Acting Chief Medical Director, Doncaster & Bassetlaw NHS Foundation Trust CORONER I am Ms N J Mundy for South Yorkshire East 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 27 January 2025 I commenced an investigation into the death of Walter Colin HORTON. The investigation concluded at the end of the inquest . The conclusion of the inquest was Narrative conclusion: Walter Colin Horton died on 10 January 2025 in Benton House Care Home from an infected sacral pressure sore. The risk of the sore becoming infected was increased due to the absence of aseptic techniques being used in wound management. 3 1a Sepsis 1b Advanced Sacral pressure sore II Ischaemic heart disease CIRCUMSTANCES OF THE DEATH This case relates to the death of a 88 year old male who passed away in a Nursing Home on Fri 10 January 2025. Referred at the request of family due to safeguarding issues and pressure sores which they felt were associated with the death. Pathologist provided a COD as: 1a) Sepsis 1b) Advanced Sacral pressure sore II) Ischaemic heart disease CORONER’S CONCERNS 4 5 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. – (1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you Nick Mallaband 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 30th October 2025. I, the coroner, may extend the period. 7 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, who may find it useful or of interest. . I have also sent it to The Secretary of State, Health & Social Care 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. 10 September 2025 8 9 HM Senior Coroner for South Yorkshire (East)
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.
Ms N J Mundy H M Coroner South Yorkshire (East District) Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Monday, 3 November 2025 Dear Ms Mundy, I write in my capacity as Chief Nurse in response to the Regulation 28 Report issued following the inquest into the death of Mr Walter Colin Horton, who sadly passed away on 10 January 2025. The report, addressed to response, with support from , Divisional Nurse for Medicine. , Chief Executive, was referred to me for a formal , Nurse Consultant for Skin Integrity, and Please find below a detailed response to the matters of concern raised in the Prevention of Future Deaths Report (PFDR), including actions taken, timeframes, and rationale where no further action is deemed necessary. 1. Record Keeping - Falls There is no record or evidence of Mr Horton experiencing a fall during his admission. A falls risk assessment was completed in accordance with Trust policy, and no DATIX incident was submitted. The ward manager has no recollection of safety concerns during Mr Horton’s stay. A mobility assessment was conducted; a hoist assessment was deferred to community services, with the care home agreeing to continue nursing in bed. Falls prevention remains a Trust-wide safety priority, with an action plan monitored through established governance processes. 2. Record Keeping and Wound Management Mr Horton was admitted with a pre-existing category 3 pressure ulcer, confirmed by photographic evidence. A safeguarding referral was made on admission in line with our Trust safeguarding procedures. Wound care was delivered in accordance with the specialist treatment plan and Trust policy, with documentation evidencing improvement. At discharge, there were no signs of infection or inflammation that could have contributed to sepsis. The Trust maintains a comprehensive skin integrity improvement plan, including regular audit, education, and training. 3. Handover Information on Discharge A discharge letter accompanied Mr Horton to the care home and was sent electronically to his GP, documenting clinical status and follow-up advice. A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group. The Trust recognises that record keeping regarding communication at discharge is a key safety improvement priority. 4. Aseptic Technique and Wound Cleanliness A detailed review found no evidence of breach in aseptic technique during wound care. Documentation confirms care was delivered in line with Trust policy, and the pressure ulcer improved during admission. There is no indication that wound management contributed to the development of sepsis. Conclusion The Trust has carefully considered the concerns raised and is committed to learning from Mr Horton’s case. The actions outlined above are intended to strengthen patient safety and enhance discharge processes across the organisation. Please accept our sincere condolences to Mr Horton’s family at this difficult time. Yours sincerely Chief Nurse Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust
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