Linda Brooks

Response to Regula(cid:415)on 28 Request 
Title 

Coroner Regulation 28 – Prevention of 
Future Deaths Report into the death of 
Linda Brooks 

Author/Role 

Accountable Executive Director 

 Associate Director of 

Patient Safety and Quality 
 Chief Nurse 

Concerns raised by the coroner leading to the Regulation 28 – Prevention of Future 
Deaths Report: 

Linda Brooks was a 78-year-old lady who died at Torbay Hospital on 17th May 2022. She 
had resided at Sundial Care Home since 2018. She fell in the care home in February 
2022, where she possibly sustained fractured ribs. She did not want to seek a chest X-ray, 
but family/doctor persuaded her to do so. Prior to this she fell again on a background of 
COVID infection, which resulted in her being admitted to Torbay Hospital on 16th April 
2022, where she remained until her death. 

On the day prior to Mrs Brooks’ death, she was an inpatient at Newton Abbot Community 
Hospital (part of Torbay and South Devon NHS Foundation Trust). Mrs Brooks was being 
weaned from oxygen prior to her discharge, and at the time she was on 0.5 litres of 
oxygen via nasal cannula. At some point during the evening of 16th May 2022 this oxygen 
was inadvertently turned off. It appears that the oxygen had been turned off for a period of 
time between 20:07 and 21:30. By 21:30 Mrs Brooks’ oxygen saturations had dropped 
significantly. The out-of-hours GP service was called and, due to the delay in attending, a 
999 call was also made. 

An out-of-hours doctor visited Mrs Brooks at 03:30 and diagnosed Mrs Brooks with an 
infective exacerbation of COPD and commenced intravenous antibiotics and intravenous 
frusemide. The GP documented that he did not think Mrs Brooks required transfer to an 
acute hospital and advised he would remain in contact via telephone as needed. 

The registered nurse remained concerned about Mrs Brooks’ condition, and her Treatment 
Escalation Plan noted that transfer back to an acute hospital would be appropriate. The 
999 call had not been cancelled and South West Ambulance Service (SWAST) transferred 
Mrs Brooks from Newton Abbot Community Hospital to Torbay Hospital, arriving at 
approximately 05:30. She was moved to the resuscitation area of the Emergency 
Department. 

Mrs Brooks did not respond to treatment within the Emergency Department; she was 
placed on the end-of-life pathway and was transferred to Forrest Ward. Mrs Brooks’ death 
was confirmed at 00:15 on 18th May 2022. 

An inquest into Mrs Brooks’ death was held on 28th and 29th January 2026. Following the 
conclusion of the inquest, the coroner issued a Regulation 28 Prevention of Future Deaths 
report. The matters of concern raised by the coroner are detailed below: 

1.  There appeared to be a lack of training and understanding by staff at the Trust that 
it is everybody’s responsibility to report and escalate a serious clinical incident 
such as this  

2.  2. There appears to be no effective process in place for reviewing clinical notes to 
pick up a clinical issue such as this in circumstances where no complaint has been 
made by a family member, and no member of staff has recognised or reported it. 

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 3.  3. There appears to be a lack of understanding as to when a Serious Incident 

Report should be made or actioned retrospectively. 

4.  4. There appeared to be no process for recording the fact that another organisation 
such as SWAST had made a Datix referral which would then have mitigated the 
fact that the SWAST team failed to pass on their own DATIX to Torbay and South 
Devon NHS Trust. 

Background: 

Linda Brooks was a 78-year-old lady who lived in a care home and had the following 
comorbidities: health anxiety, COPD, asthma, and ischaemic heart disease. She had a 
fall at her care home which caused an admission to Torbay Hospital on 16th April 2022. 

Initially no fractures were seen, and she was treated with oxygen therapy at lower levels 
than would be seen in a person without respiratory compromise because too much 
oxygen can cause a reduction in respiratory drive and further CO₂ retention in COPD 
patients. 
She was transferred from the Emergency department to Forrest Ward where rib and 
pubic Rami fractures were diagnosed and it was discovered that she had small blood 
clots. On 22nd April 2022 it was felt that given her high risk of falls and co-morbidities, 
the risks of potential bleeding if on anticoagulation, meant that the blood clots should not 
be treated, and therefore she recommenced prophylactic clot prevention dose Dalteparin.  

On 29th April 2022, multiple gastric erosions and three duodenal ulcers were diagnosed 
and treated accordingly. An increase in oxygen requirement on 4th May 2022 with a new 
change on chest X-ray led to an increase in her diuretic therapy and a switch to a 
stronger form of intravenous antibiotic for hospital-associated pneumonia. Her oxygen 
requirements fluctuated during the admission. Multiple blood gases showed that she 
remained very sensitive to over-oxygenation, which would cause her to hyperventilate 
further; therefore, it was recommended that she remain at target oxygen saturations of 
88–92%. She was gradually weaned to oxygen via nasal cannula. There was a steady 
improvement in inflammatory markers, and she was discharged to Templar Ward at 
Newton Abbot Community Hospital on 10th May. 

By the 13th of May 2022 she had weaned to a minimal level of oxygen 0.5l, she was 
found to have a new irregular heart rhythm, known as atrial fibrillation.  

Mrs Brooks was stable, eating, drinking and mobilising well and appeared to be 
improving sufficiently to begin the process of returning home when, on 16th May 2022, a 
note in the nursing records stated that Mrs Brooks’ oxygen had been turned off. This 
appears to have happened sometime between 20:07 and 21:30, when it was noted that 
oxygen was not turned on at the wall. Asked about whether someone could have 
knocked the dial inadvertently, the consensus was that it was not easily done, and 
certainly not easily done by a frail patient such as Mrs Brooks. The Hospital Matron was 
able to say that at 21:30, when this was discovered, Mrs Brooks’ oxygen saturation levels 
had dropped to a very low level as confirmed by the Consultant, well below even the 
lowest levels recommended for COPD patients (88%), namely 74%. A patient safety 

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 incident was not raised at the time, and the Trust acknowledges this oversight and 
accepts that an incident should have been raised on the DATIX reporting system at the 
time and, failing that, should have been made retrospectively (this has now been 
completed post-inquest). 

SWAST attended to convey Mrs Brooks to the acute hospital and reported an incident on 
their local risk management system (LRMS) as they were concerned that the incident 
had happened and about the attitude of staff at the hospital, but due to human error this 
incident was never shared with Torbay and South Devon NHS Foundation Trust although 
there was an established process for that to happen. 

Mrs Brooks was seen at the acute hospital where she sadly passed away on 17th May 
2022 and the Consultant who gave evidence at inquest accepted that she did not 
complete an incident on DATIX or any other type of report and neither did she escalate 
this concern as the ambulance service had already done so. 

The Inquest was not able to confirm how this error had happened as it was never 
investigated contemporaneously or at all.  

TSDFT response to HM coroners Matter of Concern 1 

1.  There appeared to be a lack of training and understanding by staff at the Trust that 
it is everybody’s responsibility to report and escalate a serious clinical incident 
such as this  

Response 

To ensure it is everybody’s responsibility to report and escalate serious patient safety 
incidents, the Trust has strengthened its patient safety governance, training, and reporting 
infrastructure. 

These roles support our clinical staff with the reporting of incidents, including education 
and training sessions for clinical staff, including medical staff. We have also just recruited 
3 new Care group Director of Nursing roles to lead governance within our care group 
structures and to support patient safety. 

The Trust have policies in place to support patient safety oversight within the organisation. 
These policies reference the expectation for staff in relation to the reporting of clinical 
incidents and the engagement of patients and families. These policies are: 

  The Incident Reporting and Management Policy [G0848]  
  Duty of Candour Policy [G2783]. 

The implementation of Patient Safety Incident Reporting Framework (PSIRF) gave a 
renewed focus on the importance of incident reporting to enhance safety insight. The Trust 
recognises that reporting and reviewing of incidents is crucial to the transition and 
embedding of PSIRF, this includes the importance of reporting unexpected patient safety 
events.  

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 A new reporting system [DCIQ] was implemented in the Trust in October 2023; the 
importance of reporting incidents formed a large part of the communication plan around 
this system. 

The Patient Safety and Incident pages on the Trust intranet state that “All staff are able 
and encouraged to report any unexpected or unintended incidents on DCIQ; permission 
from leaders/managers is not required”. The Patient Safety Team also presents at Trust 
induction for new starters to reinforce that safety is everyone’s business and that anyone 
can raise an incident. 

The Trust embraces a ‘Fantastic Fundamentals’ series, these 30-minute, monthly 
presentations cover what is required to meet the basic health requirements we must 
deliver for our patients and include presentations from the patient safety central team on 
incident reporting, duty of candour and patient feedback. 

In July 2022 the Trust implemented a weekly Patient Safety Incident Report Group 
(PSIRG) to review patient safety incidents and reporting trends, risks, and emerging 
themes, with multidisciplinary attendance and routine care group presentations. Key 
learning and insights are shared via a bi-monthly Patient Safety Newsletter on the intranet 
and through the twice-weekly ICON email bulletin. 

All staff are asked to complete the National training: ‘Essentials of Patient Safety: For all 
staff (Level 1 Part 1)’ every 3 years. ‘Essentials of Patient Safety: Access to Practice 
(Level 2)’ are available on the Trust’s learning and development hub [the Hive], with Level 
1 being essential to role. The percentage of compliance as of 19 March 2026 date was 
83.69%  

A report showing the patient safety event data from Q1-3 2025/26 by NHS Trusts showed 
that TSDFT had the highest incident reporting of any acute trust in the Southwest and 14th 
nationally, highlighting a positive reporting culture influenced by a just, learning culture. 

Since the inquest, additional community-hospital training and targeted communications 
have been delivered to reinforce incident reporting expectations, and a quarterly learning 
event programme will commence from June with incident reporting as a core topic. 
Effectiveness is monitored by the central Patient Safety Team through DCIQ reporting 
volumes and training compliance, reviewed monthly via PSIRG and escalated through 
care group governance where required. 

TSDFT response to HM coroners Matter of Concern 2 

2.  There appears to be no effective process in place for reviewing clinical notes to 

pick up a clinical issue such as this in circumstances where no complaint has been 
made by a family member, and no member of staff has recognised or reported it.  

Response 

To ensure clinical issues are identified even when no complaint is raised, the Trust now 
uses the Medical Examiner (ME) review process to systematically review deaths and 
associated records. 

The ME’s actively report identified concerns or concerns raised by the family onto DCIQ 
and highlight cases to request a structured judgement review is undertaken where care 
factors may have contributed to the death.  

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 These are then reviewed by governance leads in the care group and scored on the DCIQ 
SJR system, with any scoring 1 or 2 triggering being considered for further investigation. 
These structured judgment reviews will be considered at the weekly executive review 
meeting for consideration of a more detailed patient safety review or patient safety 
incident investigation in line with local and National PSIRF priorities. 
Effectiveness is monitored by the ME service and care group governance leads via 
completion of ME reviews and the number/timeliness of DCIQ submissions and SJRs, 
reviewed weekly at the Executive Incident Review Meeting (EIRM). 

TSDFT response to HM coroners Matter of Concern 3 

3.  There appears to be a lack of understanding as to when a Serious Incident Report 

should be made or actioned retrospectively   

Response 

To clarify when incidents require investigation (including retrospectively), the Trust has 
adopted PSIRF and uses a weekly Executive Incident Review Meeting (EIRM) to 
determine and govern the appropriate response. 

PSIRF advocates a co-ordinated, data driven and proportionate response prioritising 
compassionate engagement and involvement with staff, patients, families and carers. 

The Trust have a weekly Executive Incident Review Meeting [EIRM] where all incidents of 
which are rated moderate or above are reviewed, alongside any themes or trends from all 
incidents. The level of investigation is determined by care groups and overseen by the 
EIRM. The level of investigation is based on National and local PSIRF priorities for patient 
safety incident investigation. National priorities include (but are not limited to) any case 
where care factors are considered to have contributed to the death of a patient. This 
provides reassurance and governance. These incidents are also reviewed in the Care 
Groups. Local priorities for Trust patient safety incident investigation are delays associated 
with patient flow (ambulance, corridor care, admission to stroke unit etc); diagnostic 
delays or errors; patient discharge related incidents. 

The Trust PSIRF policy and plan is available to access on the internet and was updated in 
January 2026 following new safety insight data.  
Effectiveness is monitored by the EIRM through review of all moderate-or-above incidents 
and confirmation of agreed investigation route and completion, reviewed weekly with 
actions tracked through care group governance. 

TSDFT response to HM Coroners Matter of Concern 4 

4.  There appeared to be no process for recording the fact that another organisation 
such as SWAST had made a Datix referral which would then have mitigated the 
fact that the SWAST Team failed to pass on their own DATIX to Torbay and South 
Devon NHS Trust.  

Response 

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 To ensure incidents raised by partner organisations (e.g., SWAST) are reliably captured 
and actioned, the Trust operates a defined process to receive external referrals, log them 
on DCIQ where needed, and route them for investigation. 

Upon receipt of the incident, it is investigated by the appropriate team, this could be within 
Care Group/Service, or if a Patient Safety Incident Investigation [as agreed by EIRM], by a 
trained PSII Investigator. 

Once the investigation has been completed the outcome and learnings are shared with 
the organisation that reported it. 

The same process occurs when we identify an incident related to another organisation. 

In addition, the Trust’s incident reporting system is compliant with the national Learning 
from Patient Safety Events (LfPSE) service, supporting cross-organisational routing of 
incident reports where the incident occurred in another organisation. 

LfPSE includes functionality to indicate whether an incident occurred in the reporter’s 
organisation or another organisation, enabling forwarding to the relevant organisation; this 
functionality was not available at the time of this event. 

The most recent LfPSE data extraction (05 March 2026) showed Torbay and South Devon 
NHS Foundation Trust as the top acute trust reporter in the Southwest and the 16th acute 
trust in the country; NHS England notes that higher reporting rates may reflect a more 
open learning culture rather than reduced safety. 
Effectiveness is monitored by the central Patient Safety Team via volume and processing 
timeliness of externally sourced incidents (including SWAST referrals) received and 
logged on DCIQ, reviewed monthly with outcomes fed back to the reporting organisation. 

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