“are: The court heard that whilst the Trust has implemented a number of recommendations…”
Dated 19 Feb 2025, from the coroner for Surrey. 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 16 Apr 2025.
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 dated19 Feb 2025
- Deadline16 Apr 2025
- Published on judiciary.uk25 Feb 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey and Sussex Healthcare NHS Trust | Response publishedPublished on judiciary.uk in February 2025. |
The coroner’s concerns
are: The court heard that whilst the Trust has implemented a number of recommendations arising out of the patient safety review following Mrs Rodgers death, a number have yet to be resolved in particular: a. NICE and the National Wound Care Strategy guidance is that patients admitted to hospital have a pressure ulcer risk assessment within 6 hours of admission. This means that the first assessment will often need to be undertaken in the Emergency Department (ED). The court heard that the work to ensure that the ED completes such assessments is ongoing and not yet embedded and that there are practical difficulties, for example when ED patients were located on corridors. b. The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs. The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget. The coroner is concerned that in not completing the above recommendations arising out of the patient safety review, the Trust is placing patients at risk of early death.
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, 2025-0096
- 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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