“I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed…”
Dated 1 Sep 2021, from the coroner for South London. 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 27 Oct 2021.
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 dated1 Sep 2021
- Deadline27 Oct 2021
- Published on judiciary.uk9 Sep 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Croydon Health Services NHS Trust | Response publishedPublished on judiciary.uk in September 2021. |
The coroner’s concerns
– (1) I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E. (2) When Mr Humphries resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted.
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, 2021-0291
- 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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