“. (1) The patient appears to have been held in ED for 40+ hours during which time…”
Dated 28 Jun 2023, from the coroner for Herefordshire. 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 23 Aug 2023.
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 dated28 Jun 2023
- Deadline23 Aug 2023
- Published on judiciary.uk7 Jul 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Wye Valley NHS Trust | Response publishedPublished on judiciary.uk in July 2023. |
The coroner’s concerns
. (1) The patient appears to have been held in ED for 40+ hours during which time footwear was not removed . Necrotic Toe apparent without evidence of appropriate management or referral. (2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients' time on ED (40 hours) and in AMU (5 days) . Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent fai lure to implement pressure relieving measures. (3) The Pressure Sore acquired in Hospital contributed to the death and it is noted that pressure area care training is not mandatory within Wye Valley Trust. 6 ACTION SHOULD BE TAl(EN In my opinion action should be taken to prevent future deaths and I believe you, power to take such action . 7 have the
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, 2023-0223
- 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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