Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0563, written 6 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Nov 2025 |
|---|---|
| Reference | 2025-0563 |
| Deceased | Judith Hughes |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire and Peterborough |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Medical Officer for North West Anglia Foundation Trust (Peterborough City Hospital) 1 CORONER I am Simon MILBURN, Area Coroner for the coroner area of Cambridgeshire and Peterborough 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. 3 INVESTIGATION and INQUEST On 16 October 2020 I commenced an investigation into the death of Judith Claire HUGHES aged 86. The investigation concluded at the end of the inquest on 05 November 2025. The conclusion of the inquest was that: Judith died from natural causes. 4 CIRCUMSTANCES OF THE DEATH Judith Hughes had a past medical history of significant heart disease. She was admitted to Peterborough City Hospital on 30 July 2020 following a tonic clonic seizure, where it was also identified that she was suffering from fast ventricular atrial fibrillation and a high heart rate. These issues were treated and Judith was discharged home on 30 July 2020 at which point there was no evidence that she was in cardiac failure. Judith's cardiac function declined from this point and she was further admitted to Peterborough City Hospital on 10 August 2020 when there was clear evidence of worsening heart failure. Sadly despite ongoing monitoring and care both in hospital and in the community Judith died at home, 129 Park Road in Peterborough, at 0030 hours on 07 October 2020. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise In my opinion there is a risk that future deaths could occur unless to concern. In the circumstances it is my statutory duty to report to you. action is taken. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The Inquest heard evidence about the Trust's use of the 'Close Observation Risk Assessment' (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including 'inpatient falls during this admission' and 'previous falls'. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 January 01, 2026. 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 following Interested Persons Family NWAFT Legal Governance I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 06/11/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
RGN, BA(Hons), PgDip in HE, MA Chief Nurse / Director of Infection Prevention and Control Executive Assistant: 12 November 2025 Mr S Milburn HM Area Coroner for Peterborough & Cambridgeshire Lawrence Court Princes Street HUNTINGDON PE29 3PA Dear Sir Inquest into the death of Judith HUGHES Peterborough City Hospital Edith Cavell Campus Bretton Gate Peterborough PE3 9GZ I refer to your Regulation 28 Report addressed to the Chief Medical Officer. This has been forwarded on to me as the Chief Nursing Officer. Mrs Hughes died over five years ago on 7th October 2020. Policies and Forms are, of course, subjected to regular review. As was mentioned at the inquest the relevant Form had already been revised in 2022 (a copy of the Policy which contains this is enclosed) following a routine review of the Policy. The Enhanced Care Risk Assessment Form is used by nursing staff to calculate the risk of a patient falling in hospital. You will note that the amended Form is clearer in setting out the risk factors. ‘Previous falls in the last 12 months’ essentially refers to falls outside of the hospital setting whereas ‘Inpatient refers to a new fall during the present admission. These are separate risk factors and the Form reflects this. Our nursing staff receive training on the Policy and Forms. fall during this admission’ The relevant Policy and Form are due to be reviewed again in the next few months and we will ensure that your comments are taken into account in this process. Yours sincerely Chief Nurse / Director of Infection Prevention and Control Enc. 2025
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