“Mrs Gilbert was noted to have grade 2 tissue damage on admission to hospital”

The coroner’s concerns

a) Mrs Gilbert was noted to have grade 2 tissue damage on admission to hospital. She b) c) d) e) was assessed as being at very high risk of pressure ulcer development. Her care plan included repositioning every 1 to 2 hours. The Intentional Rounding documents show that, during her time spent on the Old Acute Medical Unit and Coleridge Respiratory Unit (1/9/23 to 20/12/23), Mrs Gilbert remained in the same position in bed for periods of many hours on multiple days. Evidence given by the tissue viability nurse was that the tissue viability team emphasised the importance of repositioning on five separate occasions to the ward staff. The lack of adherence to the repositioning plan continued despite these communications. Mrs Gilbert’s grade 2 tissue damage deteriorated to a grade 4 pressure ulcer during her admission, leading to septicaemia. The lack of adherence to the repositioning care plan for a patient at very high risk of developing pressure ulcers raises a concern for future deaths. The evidence given by the Trust at the inquest did not provide a satisfactory explanation as to why the repositioning care plan was not adhered to. This raises a concern about the quality and efficacy of the Trusts’ post-death investigation which in turn raises a concern for future deaths.

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, 2025-0061

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