“Evidence emerged during the inquest that it was crucial that patients who were at risk of…”
Dated 25 Oct 2023, from the coroner for Stoke-on-Trent and North Staffordshire. 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
All responses publishedReplies were due by 20 Dec 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 dated25 Oct 2023
- Deadline20 Dec 2023
- Published on judiciary.uk31 Oct 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in October 2023. |
| University Hospitals of North Midlands NHS TrustNamed in the report as “University Hospital’s of North Midlands” | Response publishedPublished on judiciary.uk in October 2023. |
The coroner’s concerns
– 1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours. 2. It was said that, delays in doing so, could be causative in the death of patients. 3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen.
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, 2023-0396
- 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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