Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0009, written 8 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jan 2026 |
|---|---|
| Reference | 2026-0009 |
| Deceased | Jean Waldron |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Care Home Health 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 , I g n i t e Health and Homecare Services, 1c Lowesmoor Terrace, Worcester 1 CORONER I am David REID, HM Senior Coroner for the coroner area of Worcestershire 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 25 March 2025 I commenced an investigation and opened an inquest into the death of Jean Alice WALDRON aged 79. The investigation concluded at the end of the inquest on 07 January 2026. The conclusion of the inquest was that Mrs. Waldron "died from natural causes, to which the effects of a long-standing traumatic spinal cord injury and a pressure ulcer contributed." 4 CIRCUMSTANCES OF THE DEATH Towards the end of 2024 Jean Waldron, who lived with a long-standing cervical spinal cord injury and a more recent diagnosis of vascular dementia, developed a sacral pressure ulcer, which was monitored and treated by district nurses. Around the beginning of March 2025 she developed a chest infection. Despite treatment, she continued steadily to decline, and died at her home in Worcester on 12.3.25. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) In her evidence at the inquest a carer from your agency, who was a Team Leader, gave evidence that: (a) she had read and understood an email from the District Nurse Clinical Lead, dated 15.1.25, which made clear that carers should not provide any care in relation to Mrs. Waldron's pressure sore as they did not have the correct licence to provide wound care; and (b) despite that clear instruction, she had on 3 separate occasions thereafter removed soiled wound dressings from the pressure sore and attempted to clean the wound with saline and gauze because she felt that it was in the deceased's "best interests" so to do. The lead Tissue Viability Nurse who gave evidence at the inquest said that the use of gauze was inappropriate and could have led to further adverse complications with the pressure sore. It is particularly concerning that a carer who was a Team Leader acted in the way Regulation 28 - After Inquest Document Template Updated 30/07/2021 described, and suggests that carers employed by your agency may not have received adequate training about: (a) the limits of the care which they are able to provide; and (b) the need to accept and follow advice given by specialist doctors and nurses at all times. 6 A C T I O N 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 March 05, 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. COPIES and P U B L I C A T I O N 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons W o r c e s t e r s h i r e Acute Hospitals NHS Trust 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 D a t e d : 0 8 / 0 1 / 2 0 2 6 David REID HM Senior Coroner for Worcestershire 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.
Good Morning, Regulation 28 Response – Prevention of Future Deaths Organisation: Ignite Health and Homecare Deceased: Mrs Waldron Regulation 28 Report dated: 08/01/2026 This response is provided pursuant to paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and addresses the matters of concern raised by the Coroner. Matters of Concern The Coroner expressed concern that: a carer, who was a Team Leader, undertook wound-related activity despite clear instruction not to do so; and this may indicate a lack of understanding by carers regarding the limits of their role and the need to follow specialist clinical advice. Agency Response The agency has carefully considered the evidence heard at the inquest and the Coroner’s concerns. The evidence confirms that on 15 January 2025, the District Nurse Clinical Lead issued a clear written instruction stating that carers were not authorised to provide any care in relation to Mrs Waldron’s pressure sore, as wound care fell outside the scope of practice and licensing of the agency’s sta(cid:431). The Team Leader who gave evidence confirmed that she had read and understood this instruction. This demonstrates that the agency’s communication, governance, and escalation systems were e(cid:431)ective and that sta(cid:431) were aware of the limits of care they were permitted to provide. The actions taken on three occasions thereafter were undertaken in direct contravention of that instruction, outside agency policy and training, and were not directed, authorised, or endorsed by the organisation. These actions were based on the individual’s personal judgement rather than any deficiency in the agency’s systems, training, or governance. The evidence from the Lead Tissue Viability Nurse further confirms that the actions taken were clinically inappropriate, reinforcing the necessity of carers adhering strictly to scope-of-practice boundaries — a requirement already embedded within the agency’s policies and training framework. Action Taken / Action to be Taken Without admission of fault, and in order to further reduce the risk of recurrence, the agency has taken and/or will take the following steps: 1. Scope-of-Practice Reinforcement All sta(cid:431) have received reinforced guidance clarifying that wound care and pressure sore management are outside the scope of carer practice and must only be undertaken by appropriately qualified persons. 2. Escalation and Accountability Reminder Formal reminders have been issued confirming that where clinical concerns arise, sta(cid:431) must escalate to district nursing or medical professionals and must not act independently outside authorised duties. 3. Governance Oversight Existing supervision and audit processes have been reviewed to ensure continued oversight of adherence to scope-of-practice boundaries. The agency is satisfied that these actions appropriately address the Coroner’s concerns and further strengthen safeguards already in place. Kind Regards, Operations Director Integrity, Accountability, Vision, Compassion, Purpose, Solution-Focus
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