Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0493, written 2 Oct 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 Oct 2025 |
|---|---|
| Reference | 2025-0493 |
| Deceased | Beatrice Smith |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
2 October 2025
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Chief Executive Officer, Harbour Healthcare
Limited, Lodge House, Dodge Hill, Stockport, Cheshire SK4 1RD
1) CORONER
I am Robert Cohen, HM Assistant Coroner for Cumbria
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3) INVESTIGATION and INQUEST
On 1 May 2025 I commenced an investigation into the death of Beatrice SMITH. The
investigation concluded at the end of the inquest . The conclusion of the inquest was a
narrative in the following terms:
Beatrice Smith was 88 years old. On 22nd September 2024 Mrs Smith was admitted to the
Cumberland Infirmary, Carlisle, following a fall and long lie. Mrs Smith had a serious ulcer on
her left leg. Whilst in hospital there was a period of one month during which Mrs Smith's ulcer
was not seen or treated by Tissue Viability Nurses. Following their involvement, Mrs Smith's
condition began to improve, but she had developed further ulcers including to her right heel.
Mrs Smith was discharged to Riverside Court Care Home on 13th February 2025. Whilst
resident there Mrs Smith's condition deteriorated seriously and the ulcer on her right heel
became badly infected. Mrs Smith's condition noticeably worsened from 15th April onwards.
Despite this, Riverside Court did not seek specialist attention for her and the ulcer was not
always properly dressed. Mrs Smith developed sepsis. She was admitted to the West
Cumberland Hospital, Whitehaven on 23rd April 2025. She died there at 17:01 on that day.
Neglect, being the failure to seek specialist care and wound management for Mrs Smith
following her deterioration on 15th April 2025, contributed to her death.
I concluded that the medical cause of Mrs Smith's death was:
1a Multiple Organ Failure
1b Sepsis
1c Infected Heel Ulcer
II Diabetes Mellitus, Dementia, Frailty
4) CIRCUMSTANCES OF THE DEATH
Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on Call on 17th
April 2025. They both had significant concerns about Mrs Smith's condition and the ACP
made a safeguarding referral. The ACP's note (which she wrote at the time) was as follows:
"sat in chair on arrival. evident leaking haemaserous fluid from the right foot/ankle this was
leaking underneath her sensor mat with noted blood clots on the floor from the exudate....I
was very shocked at how Beatrice was sat with her leg wound pooling out in her room under
her sensor mat. Daughter has raised concerns that this was how it was when she arrived
yesterday".
The Manager of Riverside Court attended the inquest and gave evidence. I asked her how
Mrs Smith had been allowed to develop such a poor condition. She responded that she had
attempted to find this out but had not been able to. She confirmed that she would have
expected staff to conduct rounds and that they should have addressed Mrs Smith's
deteriorating condition. She was not able to tell me why this had not occurred.
I understand that Harbour Healthcare Limited is now the owner of Riverside Court.
5) 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. –
(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite
this, and despite Mrs Smith's death, no effective internal investigation appears to have been
conducted. I am concerned that the absence of such an investigation means that
opportunities for learning are likely to be overlooked. In turn this risks residents being
exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had
been provided to staff in the light of this incident and Mrs Smith's death. She replied that it
had not. Given my concerns that Mrs Smith's condition was not well managed I am
concerned that the absence of such training and guidance risks a repeat of these events.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, the CEO of
Harbour Healthcare Limited, 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 28th November 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.
8) COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the each of the Interested
Persons in the inquest. I have also sent it to the Care Quality Commission who may find it
useful or of interest.
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.
2 October 2025
Signature
Robert Cohen HM Assistant Coroner for
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.
Harbour Healthcare Ltd The Lodge House, Dodge Hill Heaton Norris, Stockport Cheshire SK4 1RD Via Email 27th November 2025 FOC Christopher Fleming H.M Coroners Officer – HM Coroners Service Cumbria Fairfield, Station Road Cockermouth CA13 9PT Dear Mr Fleming. Re: Death Of Beatrice Smith, Riverside Care Home, Regulation 28 Response (Case Ref 15013096) I refer to your letter dated 6th October 2025 in relation to the above, please find below our response and actions in relation to this matter Harbour Healthcare Riverside Court Care Home Maryport Cumbria Regulation 28 Report to Prevent Future Deaths Response to Coroners Concerns into the Death of Mrs Beatrice Smith who passed away on 23rd April 2025 in West Cumberland Hospital following residing at Riverside Court Care Home Maryport Background Harbour Healthcare is a family run car provider established in 2012. Riverside Court Care Home was run by FSHC until it was one of a group of 19 homes as part of an acquisition to Harbour Healthcare on Friday 25th April 2025 Riverside Court is a 59 bedded Care Home with 2 communities over 2 floors offering care for individuals with nursing and residential needs and of those living with dementia and associated challenges. Our philosophy is quite simple, and we strive to provide an excellent standard of care to our residents treating them with complete dignity and respect. Circumstances of the Death Mrs Smith was seen by her daughter and by an ACP from Cumbria Health on call on 17th April 2025. They both had significant concerns about Mrs Smith’s condition, and the ACP made a safeguarding referral. Coroners Conclusion Medical Cause of Death 1a Multiple Organ Failure 1b Sepsis 1c Infected Heel Ulcer Response Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources. At the time of the incident Riverside Court was under FSHC policies and processes. If the incident had been investigated in line with our current policy and process this could have been shared as part of the inquest but as there was no evidence, we need to accept failure in process, however we are confident our updated process would give confidence that this process would be followed for any future incidents within the company. We have reviewed processes in the Home and coaching and support in key areas has been offered to the team along with refresher of training in Adults and Safeguarding and Wound Care. To validate learning competency and understanding this is done through reflective practice, and discussions at Stand-Up meetings, clinical meetings, supervisions etc. We have a Audit system in place along with an incident management system linked to a Risk Register so we have oversight as a company on key areas for monitoring and review of quality of care. Response As part of the internal Serious Untoward Incident RCA an action plan and lessons learned identified key areas of learning. There has been ongoing refresher training to all team members to support their understanding of Safeguarding of Residents Aswell as the eLearning on our ‘Your Hippo’ Training Platform related to wounds and skin there has been, and further training attended and planned with the NHS Tissue Viability Team on wound care for all team members offering direct care. The Quality Team support the home with Observational Support Visits which look at the quality-of-care planning and wound management. There is ongoing themed supervisions and coaching to key team members to suppor5t ongoing development When the nurses are completing their wound care training, they are completing reflective practice accounts to validate learning. As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroner’s inquest relating to a home and then the associated lessons learned The polices related to key areas have been shared with the team. Actions Taken 1. A Serious Untoward Incident Root Cause Analysis was completed by the Head of Safeguarding into the events from 15th April with a focus on 17th April 2025 supported by the Human Resources Business Partner (HRBP) 2. A Review of Wounds and skin risk in the Home was completed and Audited using our Viclarity System by the Registered Manager 3. A weekly wound monitoring form is then completed and updated and shared to the Operations Director, Regional Manager, Head of Safeguarding and Director of Quality for oversight and governance. 4. All team members have undertaken the Adults with Safeguarding E Learning Module to allow for refresher in this area 5. Impact and understanding of learning is being validated through reflective discussions at stand-up meetings, support visits and supervisions. 6. Riverside Court nurses have attended a wound care update by the local NHS trust and all team members who deliver care are signed up for further training and development through them early in 2026. 7. A camera is in place now to support taking regular pictures in line with guidance 8. Observational Support Visits were commenced which focused on key areas in including wound management and triangulation of care, and the team’s knowledge around safeguarding, recognising change, communication and associated actions. 9. The Registered Manager is carrying out further development and learning to the team through supervision and coaching which is being supported by the quality team for effectiveness. 10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas 11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting 12. Shared learning and updates are reinforced through the Stand-Up Meetings each day in the Care Home along with Huddles for improvements in more effective communication. 13. Riverside Court is on the focus call group which is a process by Harbour Healthcare as part of the risk register where higher risks home due to key issues are invited to a call every fortnight with key team members to review he Service Improvement Plan, check progress and offer support if needed to meet any urgent or high risk actions. 14. Our VI clarity Audit and Monitoring System captures risk through the key care indicators report each month. This then feeds into our corporate Risk Register for allowing effective response to the homes for resident safety. 15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025 16. These lessons learned are evidenced through the clinical governance meeting and stand-up meetings. 17. All Homes who transitioned to Harbour Healthcare in April 2025 are being transferred to Electronic Care Plans (PCS) commencing Jan 2026 to allow for continued improvements in governance and monitoring. All of the above measures are underpinned by the following Policies and Procedures Safeguarding Adults Policy and Procedure – Reviewed 29th Oct 2025 CPN16 Wound, Bruise and Skin Conditions Policy and Procedure Reviewed 23rd Sept 25 CCN30 -Pressure Ulcer Management Policy and Procedure Reviewed 5th Nov 25 CC18 -Infection Control Policy and Procedure – Reviewed 25th June 25 CCN12 – Sepsis Awareness Policy and Procedure – Reviewed 20th Aug 25 CP11 – Person Centred Care and Support Planning Policy and Procedure – Reviewed 7th Nov 25 ABN11 – Root Cause Analysis Policy and Procedure Reviewed 16th Sept 25 Evidence Appendix (Available if required) Appendix 1 – Serious Untoward Incident Root Cause Analysis Appendix 2 – Weekly Wound Tracker Appendix 3 – Observational Visits Appendix 4 – Presentation and Lessons Learned from Forum Appendix 5 – Training Records Appendix 6 -Viclarity Audits for Wounds Appendix 7 – Viclarity Audit for KCI and Risk Monitoring Appendix 8 – Clinical Meetings/Stand up meeting templates Appendix 9 – themed supervision/coaching Appendix 10 – Associated Record of Discussions Should you require any further information please do not hesitate to contact me. Yours Sincerely Director of Operations Harbour Healthcare
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.