Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0022, written 15 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 | 15 Jan 2026 |
|---|---|
| Reference | 2026-0022 |
| Deceased | Margaret Grimsley |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford and Wrekin |
| 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.
JOHN ELLERY H.M. SENIOR CORONER FOR SHROPSHIRE, TELFORD & WREKIN AREA H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HQ Coroner's Office: 01743 258540 Email: coroner@shropshire.gov.uk REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive – Shrewsbury & Telford Hospital Trust (SaTH) Royal Shrewsbury Hospital Mytton Oak Road Shrewsbury SY3 8XQ 1 CORONER I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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 3 February 2025 I commenced an investigation into the death of Margaret Elizabeth GRIMSLEY The investigation concluded at the end of the inquest on 6 January 2026 The conclusion of the inquest was a natural cause being Ia) frailty and advanced chronic obstructive pulmonary disease II) right sided heart failure 4 CIRCUMSTANCES OF THE DEATH Margaret Elizabeth Grimsley was admitted to the Royal Shrewsbury Hospital on the 16 December 2024 following a fall at home. Mrs Grimsley had comorbidities and was seriously ill. Sadly, she did not recover and following an infection in the last 24 to 48 hours of her life, she died while still at the hospital on the 22 January 2025. 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) The apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations as and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. (2) The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. (3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 12 March 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 family of the late Mrs Grimsley. 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 9 John Ellery H.M. Senior Coroner Shropshire, Telford & Wrekin 15 January 2026 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.
Mr John Ellery, H.M Senior Coroner H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HQ Royal Shrewsbury Hospital Mytton Oak Road Shrewsbury Shropshire SY3 8XQ 12th March 2026 Dear Mr Ellery, Thank you for your letter dated 15th January 2026 issued under Regulation 28: Report to prevent future deaths, in relation to the risks you identified examining the death of the late Margaret Elizabeth Grimsley. I write to provide details of the steps that we have taken and plan to address the issues highlighted in your letter. These issues were outlined as: 1. The apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations as and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. 2. The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. 3. It is not clear whether an upper alarm can be set and/or whether it is practice to do so. I have taken these points slightly out of order in my response. 1. The apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations as and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. 3. It is not clear whether an upper alarm can be set and/or whether it is practice to do so. The wall mounted patient monitors (not the portable monitors) have the functionality to provide an upper oxygen alarm however none of the respiratory consultants have ever worked in a hospital where this functionality is used in a ward environment. We have also enquired about common practice across the region; we are not aware of any other hospital that uses upper limit alarms in the ward setting. When interpretating the measured oxygen concentration using the oxygen saturation, the levels do not reliably correlate well with the blood oxygen levels when measured invasively by blood testing. The oxygen saturation measure is the essential measurement to monitor to ensure that the tissues are receiving enough oxygen, however in patients who are extremely unwell the relationship between the two readings can correlate poorly. The upper alarm is not used as the greatest risk to the patient is low blood oxygen levels. Using the lower alarm in patients with severe lung disease to keep oxygen levels within the required tight range is extremely challenging, and will often require frequent adjustment by the nursing staff to keep the oxygen levels high enough. When considering the poor correlation between oxygen saturations and actual blood levels as well as the higher risk of low oxygen levels, the focus on the ward is the lower alarms with regular monitoring to minimise higher results. 1. The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. I apologise that the responses of the consultant and the complaint letter were not consistent. The drafting of the response letter was compiled from the feedback of numerous team members. On reflection the response to the question about setting an upper limit should have been reviewed by the medical team to ensure it was accurate. This was not done. Given the reasons for not using the upper limits as outlined above, I can confirm that the complaint response letter was not accurate. However, the information given to the inquest by the consultant was correct and in keeping with the explanation provided in this response. I am very sorry for the upset and difficulty that this error in the original complaint response has caused. Our review of the complaint response letter failed to pick up this error before it was submitted. I hope that you are assured by the information I have been able to provide and that I have explained the differences in evidence that you reviewed at the inquest. If I can provide any further information, please do not hesitate to contact me at the above address. Yours sincerely, Executive Medical Director On behalf of Group Chief Executive
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