“During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19…”
Dated 17 Jan 2020, from the coroner for Shropshire, Telford and Wrekin. 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
Deadline passedReplies were due by 13 Mar 2020. 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 dated17 Jan 2020
- Deadline13 Mar 2020
- Published on judiciary.uk8 Feb 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Shrewsbury and Telford Hospital NHS TrustNamed in the report as “Shrewburys and Telford Hospital NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Mar 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time. (2) There was no referral to the TVN when the sore was categorised as a grade 2. (3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17. (4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19. (5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made. (6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores. (7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit. (8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff. (9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
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, 2020-0012
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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