“On her arrival at the Ann Marie Howes Rehabilitation Unit on 27th March 2024 Iris was…”
Dated 16 Apr 2025, from the coroner for Birmingham and Solihull. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 11 Jun 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated16 Apr 2025
- Deadline11 Jun 2025
- Published on judiciary.uk24 Apr 2025
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Birmingham NHS Foundation TrustNamed in the report as “UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST” | Response publishedPublished on judiciary.uk in April 2025. |
The coroner’s concerns
– 1. On her arrival at the Ann Marie Howes Rehabilitation Unit on 27th March 2024 Iris was assessed and found to have a Grade 4 Pressure Sore on her left heel which I was satisfied must have been present prior to her discharge the same day from the Queen Elizabeth Hospital. 2. I heard evidence during the inquest that Iris was at heightened risk of developing pressure sores given her co-morbidities and reduced mobility post her operation and that a Grade 4 pressure sore is the most serious type of pressure sore where bone is exposed and can therefore be at risk of infection. 3. However, apart from one entry on 13th October 2024 in the QEH electronic in patient noting records when it was recorded that Iris was complaining of pain on palpation of her left heel and a pillow was placed under her heel, there is no reference in the noting to it having been observed at any point that Iris had developed a pressure sore to her left heel during her admission at the QEH. 4. This leads to a concern that either the skin to her left heel was not being properly inspected or if it was that such inspections were not adequately noted in the electronic in-patient noting.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0191
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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