“During the Inquest I heard evidence from the Matron for Clinical Governance and Quality…”

The coroner’s concerns

During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds. I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals. The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed.

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, 2024-0119

Added to Minute Book

8 Oct 2026

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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