Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0578, written 11 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 | 11 Nov 2025 |
|---|---|
| Reference | 2025-0578 |
| Deceased | Tracey Oldfield |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Cornwall Hospitals NHS 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.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Medical Officer, Royal Cornwall Hospital 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 10/11/25, I concluded the inquest into the death of Tracey Oldfield who died in RCHT on 24/10/24 at the age of 56. I recorded the cause of death as: 1a) Hypoxic ischaemic encephalopathy and aspiration pneumonia; 1b) Cardiac arrest; 1c) Combined effects of opiate-mediated respiratory depression and an absence of CPAP respiratory support for obstructive sleep apnoea. II) End-stage renal failure complicating insulin-dependent Type 2 Diabetes Mellitus, valvular and hypertensive heart disease. I recorded a conclusion that Tracy died from complications that developed following an elective procedure resulting in an unanticipated admission into hospital. 4 CIRCUMSTANCES OF THE DEATH Tracey was a 56-year-old lady with a diagnosis of type 2 diabetes mellitus, end-stage renal failure, hypertension, obstructive sleep apnoea and peripheral neuropathy. She had been in receipt of dialysis since 2020. She had a surgical fistula to facilitate treatment, but this needed revision. On 17/10/24, Tracey underwent an elective procedure in this regard as a day case which was technically unremarkable. Post-operatively, however, she was found to have low oxygen saturations and low blood sugars. She was admitted. Ordinarily, Tracey slept with CPAP ventilation due to her sleep apnoea. 1 Information Classification: CONTROLLED She had not brought her device into hospital with her and although documented in her admission records, this was not handed over to ward staff. Additionally, Tracey was not prescribed her normal medications but instead received a standard bundle of medication for surgical patients. This included two doses of oramorph for pain relief where opiate medication was contra-indicated for a patient in end-stage renal failure. The oramorph caused Tracey to become drowsy and unresponsive which was exacerbated by the lack of CPAP ventilation. There was also no senior medical review resulting in a lost opportunity to remedy the oversights. Tracey suffered a cardiac arrest on 19/10/24 and suffered a hypoxic brain injury. She deteriorated and died in Royal Cornwall Hospital on 24/10/24 5 CORONER’S CONCERNS During the course of these inquests, the evidence has 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 have largely been identified and addressed by a Patient Safety Incident Investigation report that was available to the court. A number of changes and improvements have already been made or will be undertaken, for example, when the Trust’s IT systems are upgraded. One point that did not appear to have been fully resolved, however, centred on the need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion. On the facts of this case, Tracey was prescribed insulin when the family informed clinical staff she had a diagnosis of diabetes. Her pain relief was not prescribed at the same time, however, and as she became more uncomfortable after the nerve block used intra-operatively wore off, this resulted in her being prescribed opiates (inappropriately) rather than her usual Gabapentin. There was debate at the inquest as to who would be best placed to prepare the prescription and when. Matron done by an anaesthetist who would be reviewing the patient pre- operatively in any event. could be better done by a junior doctor when a patient was admitted and clerked in. On the facts of this case, Tracey was not seen by a junior doctor (other than to have an insulin prescription) and was not formally clerked in. (Head of Patient Safety) felt it thought it could be 2 Information Classification: CONTROLLED 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 8 January 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 of Tracey 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. 9 [DATE] [SIGNED BY CORONER] 11/11/25 3
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.
Chief Medical officer’s office
Royal Cornwall Hospital
Truro
Cornwall
TR1 3LJ
Date: 30 December 2025
Private and Confidential
Mr. Andrew Cox
H.M Senior Coroner for Cornwall and the Isles of Scilly
Pydar House
Pydar Street
Truro
Cornwall
TR1 1XU
Dear Mr Cox,
Re: The Late Tracey Oldfield – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 11 November 2025
and received on the 13 November 2025. This was issued following the inquest into the death of
Tracey Oldfield which concluded on 10 November 2025.
I would like to take this opportunity to express my sincerest condolences to the family of Tracey
Oldfield for their loss.
During the inquest, the evidence revealed a matter giving rise to concern. Which is as follows:
• How surgical day case patients who are admitted at short notice have their usual
medications prescribed in a timely fashion.
Please find below the response from the Trust and the detail of the actions being taken in relation to
the above concern.
Response:
1. A multidisciplinary group of relevant clinicians has been established to advise strengthening
existing governance related to safe, accurate and timely prescribing of a patient’s regular
medications following unexpected hospital admission following Day Case Surgery. It will
report to Clinical Effectiveness Group on 25th March 2026 for action plan sign off prior to
implementation by 27th May 2026.
2. The following 4 workstreams have been identified:
i.
ii.
iii.
iv.
v.
Identify the systems used which alert all day surgery patients with an unplanned
inpatient admission due to unexpected change in clinical condition including location,
reason for admission and responsible consultant.
Ensure all current patient data platforms triangulate and provide accurate information
on this patient subset to the site co-ordination office, responsible senior and resident
doctors. Influence the planning and implementation of the new integrated clinical care
platform, eCare to further strengthen tracking these patients.
Ensure a responsible consultant is identified and aware of the patient admission at
the time of admission. This consultant can either be the operating clinician, or the
relevant specialty on-call consultant if the admission occurs out of hours.
Strengthen resident doctor and nursing staff training and awareness of the
requirement to conduct a thorough documented clinical review (clerking) of all day
surgery patients admitted as an inpatient post operatively due to unexpected clinical
change.
Ensure medical and nursing staff adhere to existing pharmacy prescribing policies
including medicines reconciliation with a focus on ‘high risk medications’ such as
insulin, opioids, anticoagulants, psychotropics and immunosuppressants.
3. Following implementation, we will audit postoperative prescribing of all patients admitted as
inpatients following day case surgery against each of the five workstream recommendations.
This audit will be commissioned and monitored by the Clinical Effectiveness Group with an
expected completion date in September 2026. Any learning and further work identified will
be reviewed by the group 25th November 2026.
4. Immediate Response pending implementation of the above workstreams: The findings of
the PSR2 and PFD report and response will be shared with Care group leadership and
clinical governance teams at Patient Safety Incident Review Oversight Group (PSIROG), with
a request to cascade to all clinical specialty groups and teams providing day surgery services
to review and strengthen current practice to ensure patients unexpectedly admitted following
day surgery under go full clerking by a resident doctor with review of regular medications with
appropriate senior oversight.
I hope that this letter provides both you and Tracey’s family with assurance that the Trust has taken
seriously the concern you raised in your report and that the Trust has taken appropriate action to
prevent future deaths.
Yours Sincerely,
PP
, Deputy Chief Medical Officer
Chief Medical Officer
Royal Cornwall Hospitals NHS Trust
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