“(brief summary of matters of concern) I have the following concerns about the quality of…”
Dated 8 Jan 2026, from the coroner for East Sussex. 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 5 Mar 2026.
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 dated8 Jan 2026
- Deadline5 Mar 2026
- Published on judiciary.uk9 Jan 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Sussex Healthcare NHS Trust | Response publishedPublished on judiciary.uk in January 2026. |
The coroner’s concerns
(brief summary of matters of concern) I have the following concerns about the quality of clinical care David Dugdale received at Eastbourne District General Hospital (EDGH) and Conquest Hospital, Hastings: Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Poor management of David's pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol. Not until ambulance crew raised their concerns about his inadequate pain relief prior to their transferring him to Conquest Hospital did he receive increased and more appropriate pain relief. His carers repeatedly tried to advise nursing staff that he was in pain, but their concerns were not listened to nor acted upon. 2. David lost 3kgs in weight during the first month of his admission to EDGH. He was not eating nor drinking. There seemed to be little nutritional support available to David in the early stages of his admission causing him to lose almost 30kgs in total. 3. The pressure sore deteriorated to grade 4 during his admission which was a direct cause of his death. He was often found lying in soiled dressings with his pressure sore exposed and in pain by his visiting carers. 4. In spite of receiving a statement from ESHT regarding improvements in nursing care my concerns were not allayed.
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, 2026-0007
- 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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