“Infected pressure sores may have been a cause of death and they were unusual in extent…”
Dated 20 Aug 2013, from the coroner for Inner South London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 15 Oct 2013. A reply may have been sent and not yet published.
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.
- Report dated20 Aug 2013
- Deadline15 Oct 2013
- Published on judiciary.uk20 Aug 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| King's College Hospital NHS Foundation TrustNamed in the report as “King’s College Hospitals NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 15 Oct 2013. A reply may have been sent and not yet published. |
| Care Quality Commission | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 15 Oct 2013. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27'" September and 9" December. (2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 iurns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported since. (3) Nursing rotas for the period were not available. Some days were reported as below establishment. (8 by day and 6 by night for 34 patients of which at least a % were high dependency). Not all bank shifts were filled. (4) Although the ward has since been restructured and takes different cases, it was not possible to conclude that current staffing levels in ihe hospital for unconscious patients requiring regular turning were safe, as comparisons were difficult and the judgement required professional and managerial opinion.
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, 2013-0193
- 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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