“The matters that are raised in the safeguarding report:(1)Nursing notes evidence that…”
Dated 30 Sep 2020, from the coroner for Stoke-on-Trent and North Staffordshire. Sent to 3 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 26 Nov 2020, after the 56 days for replies had ended (25 Nov 2020). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated30 Sep 2020
- Deadline25 Nov 2020
- Published on judiciary.uk26 Nov 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership NHS Foundation Trust” | Response publishedPublished on judiciary.uk in June 2022. |
| Beechdene Residential Home | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Nov 2020, after the 56 days for replies had ended (25 Nov 2020). These dates can’t tell us whether a reply was due before it went online. |
| Leek Health Centre | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 26 Nov 2020, after the 56 days for replies had ended (25 Nov 2020). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– The matters that are raised in the safeguarding report:(1)Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. (2)No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas. (3)Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers. (4) The pressure mattress had been turned off on the 22.1.19 (5)No record of last visit by district nurses on the 27.1.19 (6) There was no evidence that band 4 nurse escalated the seriousness of the situation. (7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. . (8) District nurses had not involved Tissue Viability Nurses.
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, 2020-0191
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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