Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Myra Maxfield who died on 12 March 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 25 October 2023 concerning the death of Myra Maxfield on 12 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Myra’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Myra’s care have been listened to and reflected upon.

NHS England sets out our response to each of your concerns below.

1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours.

People who are bedbound are at increased risk of pressure ulcers. Healthcare professionals play a crucial role in identifying individuals who are at risk of developing pressure ulcers (using a valid and reliable risk assessment tool, as per the National Institute of Clinical Excellence (NICE) guidance below) to identify their level of risk and inform the development of an individualised plan of care. People admitted to hospital, or a care home should have their risk of developing a pressure ulcer assessed by a healthcare professional within six hours of being admitted. The National Institute of Clinical Excellence (NICE) guidance CG179 Pressure Ulcers: Prevention and Management, published April 2014, recommends that adults who have been assessed as being at high risk of developing a pressure ulcer are encouraged to change their position frequently and at least every four hours. If they are unable to reposition themselves, assistance should be offered to enable them to do so, using appropriate equipment if required, documenting the frequency of repositioning required. In cases where a patient develops a pressure ulcer, healthcare National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

11 December 2023

professionals should regularly measure and assess its depth and severity to determine the appropriate level of care and treatment. The recently published National Wound Care Strategy Programme (NWCSP) Clinical Recommendations, align with the Quality Standard from NICE and emphasise the need for assessing patient risk of pressure ulcers within six hours of hospital admission. The NWCSP was launched with the purpose to improve the quality of chronic wound care by developing recommendations for preventing, assessing and treating people with wounds to optimise healing and minimise the burden of wounds for patients, carers and health care providers. There are no specific guidelines for when patients should be referred to a Tissue Viability Specialist (TVS) within the NICE guidance or in the international best practice guidelines. You may wish to engage with NICE or the NWCSP regarding this issue.
2. It was said that delays in doing so, could be causative in the death of patients. Every organisation has a policy for preventing and managing pressure ulcers, which staff should adhere to, and should align with NICE guidance and best evidence-based practice. In the case of a patient showing signs of a severe infection that could potentially lead to death, it is expected that the patient would be promptly referred to the medical team for urgent review, treatment and appropriate intervention and management. Even if the patient was seen by the TVS (Tissue Viability Specialist) urgently, it is likely that their first course of action would be to refer the patient to the medical team for review and appropriate management and treatment.
3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen. Tissue Viability Teams across England differ in size, aligned to provider requirements with only a few providing a service seven days a week. Typically, most TVS services prioritise their referrals on Monday mornings to ensure prompt attention to urgent cases to enable them to be seen. Management and care plans are documented for the ongoing treatment and management of the patient by ward / clinical staff caring directly for the patient. NHS England is not able to provide comment on the provision of the service specifically within Royal Stoke University Hospital and would refer you to the Trust on this issue. I would like to assure you that further work has been progressed nationally to further improve pressure ulcer care and reduce the risk of harm to patients. In addition to the NWCSP, further work is also underway as part of the National Patient Safety Strategy and further work is underway to progress a diagnostic phase of improvement work in relation to pressure ulcer prevention and management.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mrs Serrano Mrs Myra MAXFIELD

Further to your letter dated 25 October 2023, I am pleased to provide a response under paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, addressing your concerns surrounding the death of Myra Maxfield.

Recorded Circumstances of the Death On the 1st April 2022, you commenced an investigation into the death of Myra Maxfield.

The investigation concluded at the end of the inquest on 15th September 2023. The conclusion of the inquest was a short narrative conclusion of: Complications following a fall on a background of natural causes.

The cause of death was: 1a) Upper gastrointestinal bleed 1b) Infected pressure ulcer following hip arthroplasty 1c) Fall II) Frailty of old age

Concerns During the course of the inquest you felt that evidence revealed matters giving rise for concern. In your opinion, matters for concern are as follows:

1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours.

2. It was said that delays in doing so could be causative in the death of patients.

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3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend and this leads to substantial delays in patients being seen.

You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

In your opinion, action should be taken to prevent future deaths.

Response:

1. As a point of clarification on the issues that you have raised in Point 1 of your letter, regarding the fact that ‘it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours’.

The NICE Pressure Ulcer Quality Standard (QS89), dated 2015: Pressure Ulcer Risk Assessment in Hospitals and Care Homes with Nursing, states that people admitted to a hospital or care home (with nursing) have a pressure ulcer risk assessment within 6 hours of admission. This is an important point of clarity, which differs from your statement that patients should be seen by the Specialist Tissue Viability Team within 6 hours of admission.

At UHNM, like other acute Trusts, The Pressure Ulcer Risk Assessment is completed by the admitting Ward/Department Registered Nurse within 6 hours of admission and 6 hours of transfer to another inpatient area. This is reflected in UHNM Trust Policy C63, Prevention and Management of Pressure Ulcers.

2. Delays may be causative in the death of patients.

Although, it is deemed best practice to complete the Pressure Ulcer Risk Assessment within 6 hours of admission/transfer a delay in completing the initial assessment may not necessarily be causative in the death of patients, as stated in Point 2 of your letter as the patient’s outcome would very much depend upon the standard of care delivered thereafter. It is current practice at UHNM to consider all patients admitted to the Emergency Department as being high risk of developing pressure ulcers so that optimal mitigating interventions are delivered in a timely manner.

Referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is available on the UHNM Trust Intranet pages.

3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend and this leads to substantial delays in patients being seen.

Mrs Maxfield was admitted to UHNM at 14:15 hrs on Friday 3rd December 2021 with an existing Category 4 Pressure Ulcer, to the spinal area, which already had a dressing in place. In the evidence presented in court it was acknowledged that there was a delay in the initial Pressure Ulcer Risk Assessment, which was assessed and documented within 11 hours of admission (as opposed to 6 hours). This was due to high staffing acuity and clinical demand during the Covid-19 Pandemic, where direct patient care was prioritised over documentation. However, it should be noted that the Pressure Ulcer was already present and had a dressing in situ during this time. An incident report was completed (ID:259932), clinical photography requested and a safeguarding referral was made within the Department, which is deemed good practice.

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The Spinal Team reviewed Mrs Maxfield and requested an MRI scan to rule out osteomyelitis and promptly commenced intravenous antibiotics.

Mrs Maxfield was referred to the Specialist Tissue Viability Team for advice about management of the existing Category 4 Pressure Ulcer on Saturday 4th December 2021 and subsequently reviewed on the next day, Sunday 5th December 2021. Ordinarily, a Category 4 Pressure Ulcer identified on admission would be reviewed by the Tissue Viability Team within 1-3 working days and on this occasion Mrs Maxfield was reviewed within 1 working day as the team were on site during that particular weekend, due to extenuating circumstances within the Trust. In addition, Mrs Maxfield was reviewed and followed up by the Tissue Viability Team on 14th December 2021 and 23rd December 2021 prior to her discharge on 23rd December
2021.

We strive to provide a high standard of care to all of our patients and preventing avoidable pressure ulcers and managing existing pressure ulcers, as in the case of Mrs Maxfield, is an important quality metric. People in hospital can be at higher risk of pressure ulcer damage but we have a range of support for teams to minimise the risk of pressure ulcer development or deterioration. UHNM provide a regular 5-Day (Monday
– Friday) Tissue Viability Service, which is in line with most acute Trusts nationally. However, as demonstrated in the case of Mrs Maxwell, a limited service is provided at weekends in extenuating circumstances on an ad hoc basis. As presented to your court by Lead Clinical Nurse Specialist for Tissue Viability and Continence, the risk of not providing a routine Tissue Viability Service at weekends is mitigated by having pathways, policies and guidance to support frontline clinicians with pressure ulcer prevention and management of existing pressure ulcers out of hours. Training in all aspects of pressure ulcer prevention and ongoing management is provided to Ward/Departmental staff.

In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is reviewed and included in UHNM Trust Policy C63, Prevention and Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the severity of the Pressure Ulcer, by our Specialist Tissue Viability Team.

I do hope that the above information provides assurance that the Trust has taken the concerns raised at the inquest seriously.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.