Marina Raisbeck
PFD Report
All Responded
Ref: 2025-0205
All 1 response received
· Deadline: 14 Jul 2025
Response Status
Responses
1 of 1
56-Day Deadline
14 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. The lack of a system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital
2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital
I am not reassured that necessary actions to address these serious issues identified are in place.
2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital
I am not reassured that necessary actions to address these serious issues identified are in place.
Responses
The Trust has immediately implemented a new initiative where a Surgical Advanced Clinical Practitioner assesses surgical patients in Bassetlaw ED daily, and has successfully rolled out a digital tracking system for acute medicine and paediatrics. They are also reviewing their transfer policy and planning to extend the tracking system to other surgical specialties.
AI summary
View full response
Dear Dr Didcock
Mrs Marina May Raisbeck (deceased)
I write to you with respect to the Regulations 28 Report issued on the 18 February 2025 to the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of Mrs Marina May Raisbeck concluded on the 16 January 2025.
The report was received by the Chief Executive’s office and forwarded to me in order to provide a response.
I have been assisted in constructing this response by Associate Chief Nurse for Patient Safety and Quality and , Consultant Physician and Trust Sepsis Lead.
I would respond to the matters of concern referred to within the PFDR as follows:
1. The lack of system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital I would like to take this opportunity of assuring you and Mrs Raisbeck’s family that the Trust adheres to standards within Royal College of Emergency Medicine (RCEM) Guidance in that whilst waiting for specialty teams to respond to a referral, the patient in question remains the responsibility of the ED team, this includes reacting to changes in the patient’s clinical condition and investigation results. These professional standards are detailed within the roles and responsibilities of the Emergency Physician in Charge (EPIC).
To enhance this standard, the Trust has immediately implemented a new initiative in Bassetlaw Hospital whereby every morning a Surgical Advanced Clinical Practitioner will undertake a face to face assessment of all surgical patients awaiting transfer to Doncaster Royal Infirmary in order to prioritise transfer. This assessment will include a full clinical review including monitoring blood tests.
In terms of transfers, historically, transport from Bassetlaw Hospital has been booked only when a bed is available on the Doncaster site. The Trust’s transfer process has been reviewed and transport and bed will now be booked at the same time; with the expectation that the patient would be transferred to the next bed available. On the rare occasions that a bed is not available on arrival at the Doncaster site, the patient will be transferred to ED under care of the specialty team.
We are in the process of reviewing the Trust’s Transfer Policy to reflect this change in practice.
2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital The Trust has successfully developed a tracking system which provides oversight to the host and receiving clinical teams and monitors the patient’s physiology parameters (including sepsis) and observations. It also enables clinical teams to prioritise patient care. This digital programme of work has already been rolled out in Acute Medicine and Paediatrics on both Bassetlaw and Doncaster Hospital sites to allow them to easily view all patients in the ED that have been referred to them.
Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months.
Meanwhile, further discussions with our wider specialties are commencing to implement the tracker for our surgical patients.
The Trust is currently embarking on a full Digital Transformation programme and in particular the implementation of an Electronic Patient Record. In view of this, we need to prioritise digital programmes with limited resources and capacity.
I trust that this will reassure you that the processes in ED around patients awaiting transfer have been made more robust as a result of the learning that has been generated through this Inquest and that the new arrangements put in place and planned will undoubtedly make it safer for patients who attend the department.
Mrs Marina May Raisbeck (deceased)
I write to you with respect to the Regulations 28 Report issued on the 18 February 2025 to the Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust following the Inquest into the death of Mrs Marina May Raisbeck concluded on the 16 January 2025.
The report was received by the Chief Executive’s office and forwarded to me in order to provide a response.
I have been assisted in constructing this response by Associate Chief Nurse for Patient Safety and Quality and , Consultant Physician and Trust Sepsis Lead.
I would respond to the matters of concern referred to within the PFDR as follows:
1. The lack of system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital I would like to take this opportunity of assuring you and Mrs Raisbeck’s family that the Trust adheres to standards within Royal College of Emergency Medicine (RCEM) Guidance in that whilst waiting for specialty teams to respond to a referral, the patient in question remains the responsibility of the ED team, this includes reacting to changes in the patient’s clinical condition and investigation results. These professional standards are detailed within the roles and responsibilities of the Emergency Physician in Charge (EPIC).
To enhance this standard, the Trust has immediately implemented a new initiative in Bassetlaw Hospital whereby every morning a Surgical Advanced Clinical Practitioner will undertake a face to face assessment of all surgical patients awaiting transfer to Doncaster Royal Infirmary in order to prioritise transfer. This assessment will include a full clinical review including monitoring blood tests.
In terms of transfers, historically, transport from Bassetlaw Hospital has been booked only when a bed is available on the Doncaster site. The Trust’s transfer process has been reviewed and transport and bed will now be booked at the same time; with the expectation that the patient would be transferred to the next bed available. On the rare occasions that a bed is not available on arrival at the Doncaster site, the patient will be transferred to ED under care of the specialty team.
We are in the process of reviewing the Trust’s Transfer Policy to reflect this change in practice.
2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital The Trust has successfully developed a tracking system which provides oversight to the host and receiving clinical teams and monitors the patient’s physiology parameters (including sepsis) and observations. It also enables clinical teams to prioritise patient care. This digital programme of work has already been rolled out in Acute Medicine and Paediatrics on both Bassetlaw and Doncaster Hospital sites to allow them to easily view all patients in the ED that have been referred to them.
Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months.
Meanwhile, further discussions with our wider specialties are commencing to implement the tracker for our surgical patients.
The Trust is currently embarking on a full Digital Transformation programme and in particular the implementation of an Electronic Patient Record. In view of this, we need to prioritise digital programmes with limited resources and capacity.
I trust that this will reassure you that the processes in ED around patients awaiting transfer have been made more robust as a result of the learning that has been generated through this Inquest and that the new arrangements put in place and planned will undoubtedly make it safer for patients who attend the department.
Report Sections
Investigation and Inquest
On 9.11.23 , I commenced an investigation into the death of Mrs Marina May Raisbeck
The investigation concluded at the end of the inquest on the 16th January 2025
The conclusion of the inquest was a narrative as follows:
Marina Raisbeck, known as May, died from sepsis, secondary to a perianal abscess, on 7.11.23 at the Doncaster Royal Infirmary (DRI). Whilst initial treatment was provided for sepsis on admission to Bassetlaw District General Hospital (BDGH) on the evening of 4.11.23, there was a delay in her reaching BDGH on that day, and then there was a further delay in transfer to the DRI for planning of the necessary Incision and Drainage of the abscess. Over the hospital admission period, her kidney function worsened, and the necessary surgery to drain the abscess on 6.11.23, also had an impact on her physiological status.
Whilst these issues of delay are serious, it is not possible to say that on balance they have caused or made a more than minimal, negligible or trivial contribution to her death, both because of the extent of her underlying frailty, and the seriousness of the infection that she faced.
The investigation concluded at the end of the inquest on the 16th January 2025
The conclusion of the inquest was a narrative as follows:
Marina Raisbeck, known as May, died from sepsis, secondary to a perianal abscess, on 7.11.23 at the Doncaster Royal Infirmary (DRI). Whilst initial treatment was provided for sepsis on admission to Bassetlaw District General Hospital (BDGH) on the evening of 4.11.23, there was a delay in her reaching BDGH on that day, and then there was a further delay in transfer to the DRI for planning of the necessary Incision and Drainage of the abscess. Over the hospital admission period, her kidney function worsened, and the necessary surgery to drain the abscess on 6.11.23, also had an impact on her physiological status.
Whilst these issues of delay are serious, it is not possible to say that on balance they have caused or made a more than minimal, negligible or trivial contribution to her death, both because of the extent of her underlying frailty, and the seriousness of the infection that she faced.
Circumstances of the Death
Marina May Raisbeck, known as May, died on 7.11.23, at the Doncaster Royal Infirmary, Doncaster, South Yorkshire. May was aged 82 at the time of her death. She had a number of significant chronic medical problems, that were being managed, including Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, (with a recent hospital admission), Chronic Kidney Disease, Ischaemic Heart Disease (leading to heart failure), and obstructive sleep apnoea. She also had morbid obesity. There was a RESPECT form in place from July 2023. May also had wound healing difficulties with leg and abdominal wounds managed by the District Nurse team. She was housebound, with an Exercise Tolerance of 5-10 yards. May developed a red painful lump on her buttock at the end of October 23. She was seen on 1.11.23, and prescribed an antibiotic, Doxycycline. It is unclear whether this was prescribed for a possible chest or water infection. It was an unusual choice for a skin infection/evolving abscess. She was seen again on 3.11.23 and the abscess was clearly noted. It was not painful, but discharging. She was appropriately prescribed
Flucloxacillin, and a District Nursing team referral made. There were no signs of sepsis on either of these occasions. On the morning of 4.11.23, she was seen by a District Nurse, who provided a dressing. No observations were taken at this appointment but May was not described as systemically unwell. Also on 4.11.23, the family had contacted the Out of Hours (OOH) service, 111, at 09.14 hours, as the 4th was a Saturday. A call back from a clinician from the Bassetlaw OOH GP service occurred at 15.27 hours-it is unclear what happened between the initial call, and the clinician call back, with May's daughter reporting a further call to the 111 service to follow up following the first call. The telephone assessment established that the abscess was now larger (5x5cm reported), and that it was red and painful. There was insufficient exploration of other systemic symptoms of infection, and this assessment should have resulted in a face to face assessment within 2 hours , rather than 6 hours as was arranged. May was then seen by a OOH GP at 19.51 hours on 4.11.23. May was identified as unwell at this point, though with normal temperature, pulse and blood pressure. This appropriately resulted in an ambulance transfer to BDGH, arriving at 21.13 hours. A nurse triage assessment followed at 21.49, where it was recognised May likely had sepsis-she now had a fever, with a low blood pressure of 95/39, a high breathing rate of 25 breaths per minute (though her breathing rate was often high at rest), pulse of 88/minute, just within the normal range. She was given a fluid bolus and IV antibiotics at 22.45, and a diagnosis of an abscess, requiring incision and drainage was made. She was accepted under the surgical team at the DRI (surgery not available at BDGH at the weekend), at 02,00am on 5.11.23. Thereafter, whilst May remained reasonably stable, her fluid balance was not recorded, and there was no repeat blood tests to monitor her lactate, and her kidney function, as should have occurred. She required two fluid boluses to improve her blood pressure, at 11.38 hours and 15.18 hours on 5.11.23 at BDGH. May was finally transferred to DRI on the evening of 5.11.23, and then incision and drainage were appropriately delayed until the morning of 6.11.23, as she was a high anaesthetic risk, and it was appropriate to delay until sufficient daytime staff were available. During surgery, which was completed appropriately, she had a period of 30-40 minutes of low blood pressure, despite treatment. Post operatively she remained drowsy. Over the subsequent 24 hours she developed worsening acute kidney injury. On the evening of 7.11.23 she had a cardiac arrest, and died shortly after. It is possible that earlier incision and drainage, on 5.11.23, would have led to a different outcome for May, but in light of her extensive medical issues leading to significant frailty, and the rapid progression of the perianal abscess leading to sepsis, despite appropriate treatment from the evening of 4.11.23, it is unlikely. There was no discussion between the Emergency Department medical team at BDGH, and the surgical team at the DRI, to consider prioritising May for transfer during 5.11.23, nor any agreed process for easy review of May's clinical parameters to again make an appropriate decision as to any need for more urgent transfer from BDGH to the DRI.
Flucloxacillin, and a District Nursing team referral made. There were no signs of sepsis on either of these occasions. On the morning of 4.11.23, she was seen by a District Nurse, who provided a dressing. No observations were taken at this appointment but May was not described as systemically unwell. Also on 4.11.23, the family had contacted the Out of Hours (OOH) service, 111, at 09.14 hours, as the 4th was a Saturday. A call back from a clinician from the Bassetlaw OOH GP service occurred at 15.27 hours-it is unclear what happened between the initial call, and the clinician call back, with May's daughter reporting a further call to the 111 service to follow up following the first call. The telephone assessment established that the abscess was now larger (5x5cm reported), and that it was red and painful. There was insufficient exploration of other systemic symptoms of infection, and this assessment should have resulted in a face to face assessment within 2 hours , rather than 6 hours as was arranged. May was then seen by a OOH GP at 19.51 hours on 4.11.23. May was identified as unwell at this point, though with normal temperature, pulse and blood pressure. This appropriately resulted in an ambulance transfer to BDGH, arriving at 21.13 hours. A nurse triage assessment followed at 21.49, where it was recognised May likely had sepsis-she now had a fever, with a low blood pressure of 95/39, a high breathing rate of 25 breaths per minute (though her breathing rate was often high at rest), pulse of 88/minute, just within the normal range. She was given a fluid bolus and IV antibiotics at 22.45, and a diagnosis of an abscess, requiring incision and drainage was made. She was accepted under the surgical team at the DRI (surgery not available at BDGH at the weekend), at 02,00am on 5.11.23. Thereafter, whilst May remained reasonably stable, her fluid balance was not recorded, and there was no repeat blood tests to monitor her lactate, and her kidney function, as should have occurred. She required two fluid boluses to improve her blood pressure, at 11.38 hours and 15.18 hours on 5.11.23 at BDGH. May was finally transferred to DRI on the evening of 5.11.23, and then incision and drainage were appropriately delayed until the morning of 6.11.23, as she was a high anaesthetic risk, and it was appropriate to delay until sufficient daytime staff were available. During surgery, which was completed appropriately, she had a period of 30-40 minutes of low blood pressure, despite treatment. Post operatively she remained drowsy. Over the subsequent 24 hours she developed worsening acute kidney injury. On the evening of 7.11.23 she had a cardiac arrest, and died shortly after. It is possible that earlier incision and drainage, on 5.11.23, would have led to a different outcome for May, but in light of her extensive medical issues leading to significant frailty, and the rapid progression of the perianal abscess leading to sepsis, despite appropriate treatment from the evening of 4.11.23, it is unlikely. There was no discussion between the Emergency Department medical team at BDGH, and the surgical team at the DRI, to consider prioritising May for transfer during 5.11.23, nor any agreed process for easy review of May's clinical parameters to again make an appropriate decision as to any need for more urgent transfer from BDGH to the DRI.
Copies Sent To
2. The Nottingham and Nottinghamshire Integrated Care Board
Inquest Conclusion
Marina Raisbeck, known as May, died from sepsis, secondary to a perianal abscess, on 7.11.23 at the Doncaster Royal Infirmary (DRI). Whilst initial treatment was provided for sepsis on admission to Bassetlaw District General Hospital (BDGH) on the evening of 4.11.23, there was a delay in her reaching BDGH on that day, and then there was a further delay in transfer to the DRI for planning of the necessary Incision and Drainage of the abscess. Over the hospital admission period, her kidney function worsened, and the necessary surgery to drain the abscess on 6.11.23, also had an impact on her physiological status.
Whilst these issues of delay are serious, it is not possible to say that on balance they have caused or made a more than minimal, negligible or trivial contribution to her death, both because of the extent of her underlying frailty, and the seriousness of the infection that she faced.
Whilst these issues of delay are serious, it is not possible to say that on balance they have caused or made a more than minimal, negligible or trivial contribution to her death, both because of the extent of her underlying frailty, and the seriousness of the infection that she faced.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Hepatologist Oversight and Fibroscan Access
Infected Blood Inquiry
Delayed Recognition of Deterioration
Annual GP Appointment for Co-morbidities
Infected Blood Inquiry
Delayed Recognition of Deterioration
Transfusion Committees and Tranexamic Acid - England
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Tranexamic Acid - Scotland, Wales and NI
Infected Blood Inquiry
Inadequate Pre-Operative Risk Assessment
Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Bristol Heart Inquiry
Inadequate Pre-Operative Risk Assessment
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.