David Dugdale

Rachel Redman 
Assistant Coroner for East Sussex 
East Sussex Coroner's Court and Office 
Westfield House 
St Anne's Crescent 
Lewes 
BN7 1UE 

5th March 2026 

Dear Ms Redman,  

East Sussex Healthcare Trust Response to Regulation 28 Report – David Joseph Dugdale 

Thank you for your letter of 8th January 2026, enclosing your formal report under Regulation 28 to 
Prevent Future Deaths you made at the conclusion of the Inquest into Mr David Joseph Dugdale’s 
death  on  19th  May  2024  (Inquest  concluded  on  21st  November  2025).  I  would  like  to  convey  my 
sincere condolences  to those who  knew  and  cared  for Mr  Dugdale  and would like  to  assure them 
that  we  have  considered  all  the  recommendations  in  the  report  and  have  made  changes  to  our 
systems as a result. 

The  Prevention  of  Future  Deaths  report  identifies  the  following  areas  of  concern,  and  we  address 
each one in turn with our findings and actions that we have undertaken, or plan to undertake. 

1.  Poor  management  of  David's  pain.  In  spite  of  sustaining  a  category  2  pressure  sore 
and  bilateral  hip  fractures  whilst  an  inpatient  at  EDGH,  he  was  only  receiving  oral 
paracetamol.  Not  until  ambulance  crew  raised  their  concerns  about  his  inadequate 
pain  relief  prior  to  their  transferring  him  to  Conquest  Hospital  did  he  receive 
increased  and  more  appropriate  pain  relief.  His  carers  repeatedly  tried  to  advise 
nursing  staff  that  he  was  in  pain,  but  their  concerns  were  not  listened  to  nor  acted 
upon. 

We recognise that Mr Dugdale did not receive adequate pain relief and recognition of pain in 
non‑verbal,  vulnerable,  and  learning‑disabled  patients  was  not  of  a  standard  we  expect,  in 
response, the following measures are to be implemented immediately. On admission clinical 
teams  are  to  liaise  directly  with  family  members  and  carers  to  establish  how  the  patient 
typically expresses pain and what interventions have previously been effective. “This is Me” 
documentation  is  requested  to  support  the  multidisciplinary  team  in  understanding  the 
patient’s  individual  needs.  All  patients  who  are  unable  to  reliably  self‑report  pain  receive  a 
structured pain assessment at least once per shift, using the learning disability pain tool and 
incorporating  carer  or  next‑of‑kin  input,  with  care‑home  documentation  used  where 
available.  Any  unresolved  pain  following  simple  analgesia,  or  pain  reported  by  carers, 
triggers  a  same‑shift  senior  nurse  review  and  medical  escalation.  In  addition,  the  Learning 
Disability Nurse completes and documents a specialist review within 48 hours of admission 
for all patients with a learning disability. 

Medical  teams  will  incorporate  a  daily  pain  checklist,  including  review  of  the  learning 
disability  pain  tool,  EPMA,  diagnostics,  and  radiologic,  to  ensure  ongoing  pain  control  and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 timely  intervention.  Care  plans  are  to  be  adjusted  based  on  the  patient’s  response  to 
analgesia,  with  clear  and  concise  documentation.  Regular  communication  is  maintained 
between  medical  teams,  nursing  staff,  carers,  next‑of‑kin,  HCAs,  and  the  Pain  Team  to 
ensure  optimal  pain  management.  For  patients  with  fractured  hip,  neck  of  femur,  or 
long‑bone  injuries,  pain  management  should  be  initiated  immediately  and  without  delay, 
including Iliofascial Nerve Block by trained clinicians in addition to Morphine, Buprenorphine 
patch, intravenous paracetamol etc. unless contraindicated. Orthopaedic teams will provide 
prompt review across both sites, and transfers from Eastbourne District General Hospital to 
Conquest via ambulance will require a completed a neck of femur fracture pain checklist to 
ensure  adequate  pain  control  prior  to  movement.  Definitive  pain  management  of  fractured 
neck of femur/long bones will be under the Orthopaedic team (surgical management) and a 
Safety  Pin  (attachment  A)  has  also  been  circulated  to  share  learning  across  divisions  and 
reinforce expectations. 

To  provide  assurance  of  sustained  improvement,  monthly  audits  of  pain  assessment 
documentation and escalation actions are now in place with the first audit scheduled within 
three months. Audit outcomes are to be reviewed at Divisional Governance, with escalation 
for  sustained  non-compliance.  Ongoing  teaching  of  the  learning  disability  pain  tool  and 
documentation  standards  occur  during  daily  medical/surgical  ward  rounds  with  priority  on 
using  the  learning  disability  pain  tool  to  help  in  pain  assessment/management  in  cases  of 
learning  difficulty,  non-verbal  and  vulnerable  patients.  We  will  continue  to  reinforce  the 
importance  of  Orthopaedic  and  Orthogeriatric  documentation  relating  to  pain  management 
and checklist.  

2.  David lost 3kgs in weight during the first month of his admission to EDGH. He was not 
eating nor drinking. There seemed to be little nutritional support available to David in 
the early stages of his admission causing him to lose almost 30kgs in total. 

On review  of the medical  records,  there is  documentation  indicating in November  2023 Mr 
Dugdale was 60.3kg, on 17th February 2024, whilst on Cuckmere Ward he was 50.8kg and 
the  last  known  recorded  weight  was  taken  on  25th  April  2024  on  Benson  and  Egerton 
Trauma Unit (BETU) as 42kg. We acknowledge this remains a significant weight loss during 
his admission and in light of this we have put the following provisions in place.  

Completing the Malnutrition Universal Screening Tool (MUST), a tool used to identify adults 
who are malnourished or at risk of malnutrition, is now required on admission and weekly as 
a  minimum.  These  should  be  monitored  by  ward  Matrons  and  Heads  of  Nursing  using  the 
LiveFlo system, if a MUST score is 2 or above or there is documented poor oral intake for 
more than 48 hours this will trigger an automatic referral to Dietetics.  In addition, nutritional 
plans  must  be  clearly  referenced  within  daily  nursing  documentation  and  where  patients 
repeatedly  refuse  nutrition  or  hydration,  this  will  trigger  a  multidisciplinary  review  (MDT) 
involving  Dietetics  and  the  Learning  Disability  Nurse,  ensuring  that  barriers  to  intake  are 
explored  and  addressed  promptly. These  measures  are  designed  to  ensure  that  nutritional 
concerns are escalated early and managed proactively. 

To  ensure  improvements  are  maintained  and  monitored  over  time,  quarterly  audits  will 
review  MUST  compliance,  referral  timelines,  and  weight‑monitoring  practices.  LiveFlo 
monitoring by Matrons and Heads of Nursing will continue to support real‑time oversight, and 
audit  results  will  be  reported  through  the  IGM.  Immediate  reinforcement  of  these 
expectations  has  already  taken  place,  audit  results  from  2025  are  already  available  and 
outlined below but we will continue an audit cycle within three to six months. 

As  above,  a  2025  audit  has  already  taken  place  (attachment  B)  which  demonstrated  the 
following;  the  overall  number  of  patients  with  a  MUST  score  calculated  on  admission  has 
increased  to  65%  compared  to  55%  last  year,  the  number  of  patients  with  MUST  scores 

 
 
 
 
 
 
 
 
 completed  weekly  has  increased  marginally  (50%  compared  to  47%  last  year)  and  the 
proportion of MUST scores completed accurately has increased to 77% from 69%.  

However,  the  rates  for  following  the  action  plan  have  decreased. The  first  line  provision  of 
nutrition  support  was  instigated  in  31%  of  cases  compared  to  45%  in  2024,  and  the 
proportion  of  individuals who  were  referred to  the Dietitian of  those  who should have  been 
had  dropped  to  37%  from  61%.  For  Benson  and  Egerton  Trauma  Unit,  the  proportion  of 
patients with at least 1 MUST score completed was good at 82%; however, the proportion of 
patients with MUST scores completed every week was one of the lowest in the Trust at 16%. 

Following  these  results,  a  pilot  project  has  recently  commenced  on  BETU  to  look  at 
improving  nutritional  standards  on  this  ward.  This  involves  additional  Dietetic  staffing  to 
improve  training,  review  of  the  equipment  available  for  measuring  nutritional  status  and 
trialling  strategies  to  improve  provision  of  high-quality  nutrition  on  the  ward.  Learning  from 
this project will be rolled out to the wider Trust. 

3.  The  pressure  sore  deteriorated  to  grade  4  during  his  admission  which  was  a  direct 
cause  of  his  death.  He  was  often  found  lying  in  soiled  dressings  with  his  pressure 
sore exposed and in pain by his visiting carers. 

Having  previously  participated  in  the  national  Commissioning  for  Quality  and  Innovation 
(CQUIN)  programme  including  CQUIN12  Prevention  and  Management  of  Pressure  Ulcers, 
that seeks to achieve 70-85% of acute and community hospital inpatients aged 18+ having a 
pressure ulcer risk assessment that meets NICE guidance with evidence of actions against 
all identified risks, it was recognised that we had not met the expected compliance rate with 
initial  audits.  These  were  undertaken  quarterly  by  the  Lead  Tissue  Viability  Nurse  on  a 
randomised selection of 100 patients and showed overall compliance was low (<50%). 

As such there have been several actions that have since been undertaken since April 2024 
to  achieve  and  maintain  long term  effectiveness  with  our  improvements.  These  have been 
led by the Pressure Ulcer Steering Group (PUSG) and the Tissue Viability Specialist Nurses.  
We  have  identified  areas  for  improvement  including  maternity,  elective  care,  and  gateway 
areas.  A  new  electronic  audit  tool  was  designed  and  implemented  in  August  2025  after  a 
pilot,  whereby  audits  are  now  undertaken  monthly  by  each  ward  auditing  a minimum  of  20 
patients.  

 
 
 
 
 
 
 
 The  table  below  demonstrates  that  the  target  compliance  of  70-85%  has  been  achieved 
each month since August 2025.The latest compliance with all 4 criteria being met was 82% 
in January 2026, of the 545 patients audited.  

To  improve  the  standard  of  information  and  communication  with  patients  and  their  carers, 
during  ‘Stop  the  Pressure’  week  in  November  2025  the  Trust  launched  new  patient 
information leaflets ‘how to prevent a pressure sore’ (attachment C). The leaflet was adapted 
from  a  national  document  designed  by  patients  for  patients  in  collaboration  with  the  then 
National Wound Care Strategy (NWCS). The leaflet is provided to all patients assessed as at 
risk of pressure damage or that have pressure damage. It provides clear information for staff 
to discuss with patients and includes an area for documentation of individual patient choices 
or specific advice given. It remains with the patient during the hospital stay and, in the home, 
and can also be used for sharing treatment plans with carers and relatives. 

We also worked in partnership with NHS Sussex and other health care providers in Sussex 
to agree a mandatory framework for education and training related to wound care for clinical 
staff  including  pressure  ulcers  in  line  with  the  National  Wound  Care  Strategy  Programme 
(NWCSP).  This  includes  eLearning  and  face  to  face  taught  elements  and  different  tiers  or 
levels of training are required for staff in different roles (attachment D). The Tissue Viability 
Nurses  also  provide  face  to  face  training  as  part  of  the  mandatory  induction  and 
preceptorship  training  for  newly  qualified  or  new  to  Trust  nurses.  In  addition  to  the 
mandatory  training,  the  Trust  has  also  introduced  essential  training  days  for  clinical  staff 
which provides training  in human  factors  and  simulated scenarios  related to  patient  safety, 
for a blended and interactive approach to learning. This includes pressure ulcer prevention 
and management. This programme was developed by the Trust Deputy Chief Nurse with the 
Education and Training Team. 

As  part  of  the  QI  project  commissioned  by  the  Pressure  Ulcer  Steering  Group  (PUSG)  on 
Benson and Egerton Traum Unit (BETU), additional bitesize face to face training has been 
piloted  on  the  ward  and  on  bespoke  study  days.  The  feedback  and  evaluation  have  been 
positive  and  reported  back  to  the  PUSG  with  a  strong  preference  for  face-to-face  learning 
compared to mandatory eLearning. In turn PUSG requested the NHS Sussex Wound Care 
Group  undertake  an  evaluation  of  the  mandatory  training  framework,  however  the  group 
disbanded in early 2026. As a result, the PUSG is planning to undertake a formal evaluation 

 
 
 
 
 
 of  the  Trust  during  2026-27.  Any  proposed  recommendations  and  changes  to  Trust 
mandatory  and  essential  training  will  require  a  proposal  to  be  approved  by  the  Trust 
Education Oversight Group. 

The  Tissue  Viability  Nurses  regularly  provide  targeted  face  to  face  training  in  wards  and 
departments  where  requested.  These  can  be  ad  hoc  in  response  to  incidents  or  identified 
knowledge  gaps  by  department  leads  or  on  pre-planned  routine  ward  study  days  with 
several topics covered, similar to BETU ward. Wards such as Cuckmere ward have received 
face  to  face  training  sessions,  with  some  receiving  ongoing  1-hour  sessions  monthly  and 
pressure  ulcer  training  every  2  months.  BETU  ward  have  introduced  PFD  focussed  study 
days  in  2025/26  which  include  2-hour  face  to  face  pressure  ulcers  sessions.  The  training 
being  provided  also  incorporates  the  Pressure  Ulcer  Prevention  Policy  update,  dated 
15/10/2025 (attachment E), the review of Nervecentre pressure ulcer documentation and the 
importance  of  medical  photography  in  supporting  pressure  ulcer  management  and 
surveillance.  Quarterly  newsletters  for  learning  related  to  wound  care  and  pressure  ulcers 
are also regularly circulated, and OSKA pressure ulcer webinar events are regularly shared 
via email by the Matrons as they arise. 

Alongside the above, the PUSG plans several educational and promotional events for staff 
and  patients  during  national  ‘Stop  the  Pressure  Week’  in  November.  The  events  rotate 
between hospital sites and community locations to encourage a range of attendees from all 
settings. The programme of events for these days is planned and coordinated by the tissue 
viability team and are designed to meet the most recent priorities or areas for improvement 
identified  by  learning  from  incidents  and  Inquests  (attachments  F&G).  A  programme  of 
work/activity  is  developed  annually  by  the  trust  Pressure  Ulcer  Steering  Group  (PUSG)  to 
reduce  risk  of  pressure damage  based  on  learning from  previous  incidents,  Inquests,  audit 
findings  and  national  guidance  and  recommendations.  The  PUSG  meets  bi-monthly  and 
updates  progress  against  these  plans  and  reports  to  the  Trust  Information  Governance 
Meeting  and  Quality  and  Safety  Committee.  The  programme  of  work  over  the  last  2  years 
has  included  learning  and  actions  from  the  Inquest  and  the  Prevention  of  Future  Death 
Report (attachments H&I).  

It is important to the Trust that we continue to make substantial and meaningful changes as 
this is an ongoing Trust-wide project that has significant impact on patient care, we intend to 
continue  monitoring  hospital  acquired  pressure  ulcers  by  category,  monthly  auditing  and 
monitoring of compliance with CQUIN12 PU Prevention and Management in line with NICE 
Guidance,  this  has  been  piloted  and  added  to  the  EIC  audits  which  showed  overall 
compliance in January 2026 was 84.4%, and continued oversight through the Pressure Ulcer 
Group and IGM. 

4.  In spite of receiving a statement from ESHT regarding improvements in nursing care 

my concerns were not allayed. 

The Trust recognises that previous actions focused primarily on awareness and training and 
did  not  sufficiently  demonstrate  sustained  control  of  risk.  The  Trust  is  focusing  on 
strengthening  systems,  escalation  pathways,  executive  oversight  and  measurable 
assurance,  consistent  with  national  expectations  for  patient  safety  to  reduce  the  risk  of 
similar harm in the future. 

The  Trust  acknowledges  the  risk  associated  with  failing  to  respond  to  repeated  concerns 
raised  by  carers,  and  several  actions  have  been  implemented  to  strengthen  listening, 
communication,  and  escalation  culture.  On  the  day  of  admission,  or  as  close  to  this  as 
possible,  ward  staff  now  jointly  plan  care  with  carers  and  family  members  to  establish  an 
agreed  baseline  and  clarify  how  changes  in  the  patient’s  condition,  such  as  how  they 
express  pain,  should  be  communicated.  All  concerns  raised  by  carers  regarding  pain, 

 
 
 
 
 
 
 
 
 deterioration, or unmet needs must be documented and acted upon. Alongside this, a Trust 
wide  project  and  a  Sussex  wide  working  group  are  focusing  on  improving  communication, 
support, and integration of carers, recognising that while system wide change will take time, 
these programmes will drive incremental improvements.  

initiative,  supported  by 

A  theatre‑specific  project  is  also  underway  to  enhance  communication  with  patients  with 
learning  disabilities  and  their  carers.  The  Trust  acknowledges  that  patient  passports  are 
inconsistently  updated  and  used,  and  a  Trust  wide 
the 
Transformation  Team,  will  raise  awareness and  improve  staff  understanding  of  how  to  use 
passports  effectively.  Where  concerns  persist  or  remain  unresolved,  staff  are  required  to 
escalate  via  Martha’s  Rule  if  carers  or  family  have  not  already  done  so.  Since  September 
2025, intensive work has been undertaken to raise the profile of Martha’s Rule through Trust 
its 
communications,  posters,  and 
implementation.  Communication  with  patients  with  learning  disabilities  and  those  with 
cognitive impairment has also been proposed as a ‘Quality Account’ initiative for 2026/2027 
to ensure sustained organisational focus. Any failure to escalate concerns appropriately will 
be reviewed as a patient safety incident. Assurance will be provided through ongoing review 
of Martha’s Rule activations and outcomes, with themes monitored at IGM.  Implementation 
of the above will be immediate with continuous monitoring. 

the  appointment  of  a  dedicated  nurse 

lead 

to 

Regarding  patients  who  lack  capacity  and  have  no  family  advocate  available,  an  early 
referral to an Independent Mental Capacity Advocate (IMCA) is now required for all high‑risk 
decisions.  This  ensures  that  patients  receive  the  necessary  support  at  the  earliest 
opportunity. Hospital Care Plans must be uploaded to Nervecentre and actively referenced 
within  daily  care  documentation  so  that  staff  have  immediate  access  to  up‑to‑date 
information on the patient’s needs, risks, and agreed approaches to care. Learning Disability 
MDT  oversight  is  expected  for  all  complex  or  prolonged  admissions.  While  this  should 
already occur, with MDTs inviting the Learning Disability Nurse into discussions early in the 
patient’s  journey,  this  does  not  always  happen  consistently.  There  will  therefore  be  a 
renewed  focus  on  raising  awareness  across  all  clinical  teams  to  ensure  that  the  Learning 
Disability Nurse is involved promptly and appropriately.  

The  Trust  currently  employs  a  single  Learning  Disability  Nurse  whose  role  is  to  act  as  a 
subject  matter  expert,  advisor,  and  lead  for  complex  cases.  A  business  case  is  being 
developed to explore additional support, with the aim of appointing one additional Learning 
Disability Nurse per ESHT site to improve coverage and responsiveness.  Additionally, as a 
potential alternative, the Learning Disability Nurse is exploring with local support groups and 
the  Trust’s  volunteer  services  to  consider  how  volunteers  may  help  maintain  more  regular 
contact  with  patients  with  learning  disabilities  and  their  carers  and  feeding  back  relevant 
information  to  the  Learning  Disability  Lead.  Audits  will  review  the  timeliness  of  IMCA 
referrals  with  the  first  audit  scheduled  within  six  months  and  the  Learning  Disability  Nurse 
will continue to report into Safeguarding and Quality forums to ensure appropriate oversight 
and organisational learning.  

I hope this letter provides you and those who knew and cared for Mr Dugdale with assurance that 
we  have  taken  the  learning  extremely  seriously  and  have  made  significant  improvements.  Once 
again, my sincere condolences to Mr Dugdale’s family and friends. 

Yours sincerely, 

Chief Executive Officer