“(brief summary of matters of concern) I heard evidence that it was important that Mr…”

The coroner’s concerns

(brief summary of matters of concern) I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures. The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either nor being done or not being properly recorded for some patients. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis. Of particular note is the following: 1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24, 2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24 3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24 4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11 5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24 6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24 7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03. These records therefore have gaps of up to 27 hours. In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded. The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage.

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, 2025-0343

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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