“Mr Reid died as a consequence of sepsis caused by a combination of a urinary tract…”
Dated 28 Nov 2024, from the coroner for Devon, Plymouth and Torbay. 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 publishedOrganisations 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 Nov 2024
- Deadline23 Jan 2025
- Published on judiciary.uk11 Mar 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal Devon University Healthcare NHS Foundation TrustNamed in the report as “Royal Devon University Healthcare Foundation Trust” | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
(1) Mr Reid died as a consequence of sepsis caused by a combination of a urinary tract infection (UTI), pressure sores and pneumonia; it was established during the evidence that it would not be possible to determine to what extent the infection resulting from the UTI, the pressure sores and the pneumonia individually contributed to the cause of death. (2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that: a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy. b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy. c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded. d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy. e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have moved for 5-10 hours. This is not best practice. f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression. g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
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, 2025-0135
- 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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