Janet Tripp

Chief Medical officer’s office 
Royal Cornwall Hospital 

Truro  

Cornwall 
TR1 3LJ 

Date: 25 March 2026 

Private and Confidential  
Mr. Guy Davies 
H.M Assistant Coroner for Cornwall and the Isles of Scilly 
Pydar House 
Pydar Street 
Truro 
Cornwall 
TR1 1XU 

Dear Mr Davies  

Re: The Late Mrs Janet Tripp  – Regulation 28 PFD Report and Response 

I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 09 February 2026 
and received on the 12 February 2026 This was issued following the inquest into the death of Mrs 
Janet Tripp which was heard on 18 December 2026. I understand the Matron who provided a report 
was unavailable to attend the hearing on 18 December 2026 due to pre-planned annual leave. 

I would like to take this opportunity to express my sincerest condolences to the family of Mrs Tripp 
for their tragic loss.  

During the inquest, the evidence revealed matters giving rise to concern. Which are as follows: 

1.  There was in sufficient evidence before the Court to indicate that the following failings found 

at inquest had been addressed by the Hospital: 

o  Lack of care rounds by staff 
o  Lack of training regarding basic patient care for some staff working in the discharge 

lounge 

o  Janet was not re-positioned every 2 hours as is required to avoid pressure sores 
o  No risk assessment was conducted in the duration of Janet’s stay in the discharge 
lounge or following the discovery of the pressure sores when Janet was still in the 
discharge lounge 

o  No  documentation  that  dressings  were  required  following  the  discovery  of  Janet’s 

pressure sore 

o  No  handover  notes  to  the  ambulance  service  or  Helston  hospital  warning  of  the 

development of pressure sores and the need for protective measures. 

                          
 
 
 
 
 
 
 
 
 
                                                         
 
 
 Please  find  below  the  response  from  the  Trust  and  details  of  the  actions  taken  in  relation  to  the 
above concerns. 

Response: 

I reiterate the contents of paragraph 8 – 11 of Matron Keogh’s statement dated 13 November 2025 

which confirmed the following:  

•  Nursing documentation indicated that care rounding had been carried out every two 

hours in line with RCHT policy whilst Mrs Tripp was on the Trauma Unit and this 

continued in the Discharge Lounge. 

•  Whilst on the Discharge Lounge, a healthcare professional identified a blister on 

Mrs Tripp’s right heel. The issue was raised, and appropriate pressure care was 

initiated by elevating the foot on a pillow. This had been documented in the notes on 

the 22.07.2024 @ 17:15 hours. 

• 

The  following  Learning  Point  has  been  taken  from  Mrs.  Tripp's  case.  While  skin 

bundles  were  completed  as  per  protocol,  there  is  an  important  learning  outcome 

regarding  the  need  to  ensure  documentation  and  reassessment  are  undertaken 

whenever new clinical findings arise, particularly prior to any patient transfer. Nursing 

documentation indicates that staff had elevated the patient's heels on a pillow in order 

to relieve additional pressure. However, there was no documentation to suggest that 

dressings were required. The identified learning points will focus on the importance 

of timely reassessment and identification of required needs, to include repositioning 

advice if required. All new findings, reflections and learning are discussed during our 

safety  briefing  and  subsequently  shared  with  nursing  staff  through  the  monthly 

newsletter 

• 

In addition to the information provided by Matron Keogh, to support good 

communication on the discharge lounge, a verbal ‘safety brief’ in held at each shift 

handover to ensure patients who are in the Discharge Lounge have their care 

rounds and other needs completed and ensure this is correctly documented.  

• 

Training concerns – All staff working within the Discharge Lounge are required to 

complete the organisation’s essential mandatory training programme, alongside any 

role-specific clinical skills competencies.  

Compliance with mandatory training is monitored by the Unit Leader, with additional 

oversight and support provided by the Clinical Practice Educator (CPE) team. Any 

gaps in compliance are actively followed up on to ensure that staff maintain the 

required level of knowledge and competence for safe patient care. 

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 In addition, the Division has recently increased its focus on pressure ulcer 

prevention and on the fundamentals of patient assessment. Targeted education 

sessions have been delivered to reinforce the importance of timely and accurate 

assessments, clear documentation, and proactive risk identification. Staff are being 

supported in developing a stronger understanding of their responsibilities for 

escalating concerns and communicating identified risks effectively to all members of 

the multidisciplinary team. 

The Unit Leader, in collaboration with the CPE team, will continue to monitor 

training compliance and practice standards to ensure that all staff in the Discharge 

Lounge maintain the skills and confidence required to provide safe, high-quality 

basic care to all patients. As of 28th February 2026, the overall training compliance 

for the discharge lounge is 84.5%, including all non-registered staff who are 

compliant with the HCSW (Band 3) Clinical Skills Core Competencies. The updated 

training figures from March 2026 will be available from early April 2026 and can be 

provided if required. 

•  Handover concerns re SWAST/Community Hospital - We acknowledge the 

concerns raised regarding the absence of documented handover to both the 

ambulance crew and Helston Hospital, particularly regarding the development of 

pressure damage and the need for protective measures. We also recognise that the 

SBARD forms completed at the point of transfer were not signed by a registered 

nurse and did not include timings, which falls below expected standards of 

documentation and governance. 

Following internal review, it was identified that while Helston Hospital’s SBARD did 

include reference to a “blister to the right heel,” this information was not formally or 

consistently communicated as part of a structured handover from the Discharge 

Lounge. The lack of a clearly identifiable RN signature and the absence of time-

stamping on the SBARD documentation further hindered continuity of care and 

compromised clarity regarding the patient’s condition at the point of transfer. 

We also acknowledge the concern regarding the retrospective documentation 

recorded by the registered nurse at 17:15 hours, noting Mrs Tripp’s arrival in the 

Discharge Lounge that morning and her discharge at 18:43 after a total stay of over 

seven hours. While the medication handover was appropriately completed in line 

with EMPA requirements and TTOs were provided to the transport team, the delay 

and retrospective nature of the clinical record did not meet the required standards 

for real-time documentation and handover completeness. 

In summary, the Division has implemented the following actions: 

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 •  Reinforcement of SBARD standards: All staff in the Discharge Lounge have 

received updated guidance and education on the requirement for SBARD forms 

to be fully completed, including mandatory timing and a registered nurse’s 

signature. Compliance will be reviewed through monthly documentation audits. 

•  Structured handover expectations: A standardised handover process has 

been introduced for all patient transfers from the Discharge Lounge, including 

mandatory communication of any identified risks—particularly pressure damage 

or vulnerability—and confirmation that this has been verbally acknowledged by 

the receiving team. 

•  Real-time documentation reminder process: Unit leadership has reinforced 

with all registered staff the requirement to document care contemporaneously. 

Spot checks of nursing notes are being undertaken to ensure improvements and 

identify any additional training needs. 

•  Focused education on pressure ulcer risks: In conjunction with the Clinical 

Practice Educator team, staff have been trained on the importance of 

recognising early skin changes, documenting these accurately, and escalating 

them promptly to the multidisciplinary team and receiving services. 

These measures aim to ensure that all future handovers from the Discharge Lounge are accurate, 

timely, and complete, thereby supporting continuity of care and reducing the risk of avoidable 

harm. 

I hope that this letter provides both you and  Mrs Tripp’s family with assurance that the Trust has 

taken seriously the concerns raised in your report and that the Trust has taken the appropriate action 

to prevent future deaths.  

Yours Sincerely 

Chief Medical Officer 
Royal Cornwall Hospitals NHS Trust 

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