Geoffrey Gudgeon
PFD Report
All Responded
Ref: 2026-0095
All 2 responses received
· Deadline: 13 Apr 2026
Coroner's Concerns (AI summary)
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.
View full coroner's concerns
1) The inquest heard evidence from , stroke consultant, that, at the time of these events, only 35% of patients were admitted to a stroke unit from an ED within 4.5 hours, while only 55% of patients were spending over 90% of their time on a stroke unit. Further, that there were approximately 80 admissions of stroke patients/month or about 900/year. The obvious concern was that there was a capacity issue in Cornwall concerning the timely admission and treatment of stroke patients.
Responses
Action Taken
Royal Cornwall Hospitals NHS Trust has improved stroke care by ringfencing stroke beds, increasing consultant availability in ED and Phoenix Ward, and reviewing data, leading to significant improvements in timely stroke unit admissions. A cross-organisational working group will also form to develop a business case for capacity and workforce planning. (AI summary)
Royal Cornwall Hospitals NHS Trust has improved stroke care by ringfencing stroke beds, increasing consultant availability in ED and Phoenix Ward, and reviewing data, leading to significant improvements in timely stroke unit admissions. A cross-organisational working group will also form to develop a business case for capacity and workforce planning. (AI summary)
View full response
Dear Mr Cox, Re: The Late Mr Geoffrey Gudgeon - Regulation 28 PFD Report and Response I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 16 February 2026 and received on the 17 February 2026 This was issued following the inquest into the death of Mr Geoffrey Gudgeon which was heard on 16 February 2026. I would like to take this opportunity to express my sincerest condolences to the family of Mr Gudgeon for their loss. During the inquest, the evidence revealed matters giving rise to concern. Which is as follows:
1. There is a capacity issue in Cornwall concerning timely admission and treatment of stroke patients. Please find below the response from the Trust and details of the actions taken in relation to the above concern. Response: The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly ringfencing stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of Outstanding Care for One + All □□ disability □3 confident
------- EMPLOYER ------- VETERAN AWARE
stroke patients were admitted to Phoenix Ward within 4 hours. This improved in the available 2025/2026 data, with 52% patients achieving the 4-hour target, and was accompanied by a sustained reduction in stroke mortality. I attach a copy of the Stroke Metrics to support this and if it would be of assistance, I can share with you the Stroke Action Plan for information. All the above are reported through the Trust Quality Assurance Committee on a monthly basis. From December 2025 to date, we have however seen a down-turn in our 4-hour stroke unit target. This is impacted by the number of beds across the entire stroke pathway, including Stroke Rehabilitation Unit beds when a patient no longer requires an acute stroke bed at RCHT. The current bed base was calculated on models that are now several years old and does not take into account the significant increase in stroke numbers seen. CIOS ICB has undertaken to review this provision. Patient flow is also linked to staffing, particularly within the therapy teams, which are not currently staffed to national guidelines. The ICB has also undertake to review this provision. The RCHT Stroke Improvement Board have called for urgent capacity/ demand work and bed modelling. As described, responsibility for this action lies with the ICB. A multi-stakeholder discussion regarding the development of a unified, system-wide Integrated Stroke Pathway Capacity and Demand Model across Royal Cornwall Hospitals NHS Trust (RCHT), Cornwall Foundation Trust (CFT), and NHS Cornwall & Isles of Scilly ICB took place on 4th March 2026. The aim is to establish a consistent, efficient, and clinically robust stroke pathway supported by accurate modelling, sustainable workforce planning, and strengthened governance. This meeting led to an agreement that a cross-organisational working group be formed to deliver a business case including up to date capacity and demand modelling outputs, and a robust workforce plan with new models of care, with a timeframe of 3 months. I hope that this letter provides both you and Mr Gudgeon’s family with assurance that the Trust has taken seriously the concerns raised in your report and that the Trust has taken the appropriate action to prevent future deaths.
1. There is a capacity issue in Cornwall concerning timely admission and treatment of stroke patients. Please find below the response from the Trust and details of the actions taken in relation to the above concern. Response: The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly ringfencing stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of Outstanding Care for One + All □□ disability □3 confident
------- EMPLOYER ------- VETERAN AWARE
stroke patients were admitted to Phoenix Ward within 4 hours. This improved in the available 2025/2026 data, with 52% patients achieving the 4-hour target, and was accompanied by a sustained reduction in stroke mortality. I attach a copy of the Stroke Metrics to support this and if it would be of assistance, I can share with you the Stroke Action Plan for information. All the above are reported through the Trust Quality Assurance Committee on a monthly basis. From December 2025 to date, we have however seen a down-turn in our 4-hour stroke unit target. This is impacted by the number of beds across the entire stroke pathway, including Stroke Rehabilitation Unit beds when a patient no longer requires an acute stroke bed at RCHT. The current bed base was calculated on models that are now several years old and does not take into account the significant increase in stroke numbers seen. CIOS ICB has undertaken to review this provision. Patient flow is also linked to staffing, particularly within the therapy teams, which are not currently staffed to national guidelines. The ICB has also undertake to review this provision. The RCHT Stroke Improvement Board have called for urgent capacity/ demand work and bed modelling. As described, responsibility for this action lies with the ICB. A multi-stakeholder discussion regarding the development of a unified, system-wide Integrated Stroke Pathway Capacity and Demand Model across Royal Cornwall Hospitals NHS Trust (RCHT), Cornwall Foundation Trust (CFT), and NHS Cornwall & Isles of Scilly ICB took place on 4th March 2026. The aim is to establish a consistent, efficient, and clinically robust stroke pathway supported by accurate modelling, sustainable workforce planning, and strengthened governance. This meeting led to an agreement that a cross-organisational working group be formed to deliver a business case including up to date capacity and demand modelling outputs, and a robust workforce plan with new models of care, with a timeframe of 3 months. I hope that this letter provides both you and Mr Gudgeon’s family with assurance that the Trust has taken seriously the concerns raised in your report and that the Trust has taken the appropriate action to prevent future deaths.
Action Planned
• The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. • This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow. • A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case. (AI summary)
• The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. • This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow. • A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case. (AI summary)
View full response
Dear Mr Cox
Re: Regulation 28 Report to Prevent Future Deaths – Geoffrey Gudgeon
Thank you for your report dated 16 February 2026 following the inquest into the death of Mr Geoffrey Gudgeon. I am writing on behalf of NHS Cornwall and Isles of Scilly Integrated Care Board in response to your Regulation 28 Report to Prevent Future Deaths issued following the inquest into Mr Gudgeon’s death. First and foremost, we offer our sincere condolences to Mr Gudgeon’s family.
The ICB accepts that the concern raised through the inquest highlights a material system capacity risk within the Cornwall stroke pathway, with direct implications for timely access to specialist stroke assessment and treatment. We note the evidence heard that, at the time of the events in question, 35% of patients were admitted to a stroke unit from the Emergency Department within 4.5 hours and 55% spent more than 90% of their time on a stroke unit.
More recent data for the Cornwall stroke pathway indicates improvement in direct admission to the stroke unit within 4 hours, rising from 38% in 2024/25 to 52% in the available 2025/26 data. However, system pressures across the wider pathway have remained evident since December 2025, reflecting ongoing capacity constraints.
The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow.
This work reflects the system’s recognition that the issue is not limited to acute stroke bed capacity alone, but relates to wider pathway resilience, including rehabilitation provision, workforce capacity, and patient flow across organisational boundaries. A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case incorporating demand and capacity modelling, workforce requirements, governance arrangements, service options, financial implications, and key risks and mitigations.
This work is underway and is intended to address the risks identified through the inquest by improving pathway resilience and reducing delays in access to specialist stroke care. This programme is being progressed to an agreed timetable, with immediate commencement of modelling work and a three-month timeframe for completion of the business case to inform future system decisions. The ICB will continue to review progress and work collaboratively with partners to support delivery of the required improvements.
Re: Regulation 28 Report to Prevent Future Deaths – Geoffrey Gudgeon
Thank you for your report dated 16 February 2026 following the inquest into the death of Mr Geoffrey Gudgeon. I am writing on behalf of NHS Cornwall and Isles of Scilly Integrated Care Board in response to your Regulation 28 Report to Prevent Future Deaths issued following the inquest into Mr Gudgeon’s death. First and foremost, we offer our sincere condolences to Mr Gudgeon’s family.
The ICB accepts that the concern raised through the inquest highlights a material system capacity risk within the Cornwall stroke pathway, with direct implications for timely access to specialist stroke assessment and treatment. We note the evidence heard that, at the time of the events in question, 35% of patients were admitted to a stroke unit from the Emergency Department within 4.5 hours and 55% spent more than 90% of their time on a stroke unit.
More recent data for the Cornwall stroke pathway indicates improvement in direct admission to the stroke unit within 4 hours, rising from 38% in 2024/25 to 52% in the available 2025/26 data. However, system pressures across the wider pathway have remained evident since December 2025, reflecting ongoing capacity constraints.
The ICB is leading a system-wide programme of review and improvement in relation to stroke capacity and pathway provision. This includes development of a unified integrated stroke pathway, strengthened cross-organisational governance, and updated demand and capacity modelling covering bed capacity, workforce, therapy provision, and patient flow.
This work reflects the system’s recognition that the issue is not limited to acute stroke bed capacity alone, but relates to wider pathway resilience, including rehabilitation provision, workforce capacity, and patient flow across organisational boundaries. A cross-organisational working group has been established, with a three-month timeframe agreed for development of a business case incorporating demand and capacity modelling, workforce requirements, governance arrangements, service options, financial implications, and key risks and mitigations.
This work is underway and is intended to address the risks identified through the inquest by improving pathway resilience and reducing delays in access to specialist stroke care. This programme is being progressed to an agreed timetable, with immediate commencement of modelling work and a three-month timeframe for completion of the business case to inform future system decisions. The ICB will continue to review progress and work collaboratively with partners to support delivery of the required improvements.
Sent To
- Royal Cornwall Hospitals NHS Trust
Response Status
Linked responses
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56-Day Deadline
13 Apr 2026
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
Report Sections
Investigation and Inquest
On 16/2/26, I concluded the inquest into the death of Geoffrey Gudgeon who died in Poldhu Nursing Home, Mullion on 1/12/24 at the age of 89.
I recorded the cause of death as 1a) Ischaemic stroke.
I recorded a conclusion that Geoffrey died from Natural Causes.
I recorded the cause of death as 1a) Ischaemic stroke.
I recorded a conclusion that Geoffrey died from Natural Causes.
Circumstances of the Death
On 11 June 2024, Geoffrey suffered a spontaneous ischaemic stroke. He was admitted the next morning to West Cornwall Hospital where, after a CT scan, his diagnosis was confirmed. , WCH consultant contacted the stroke unit at RCHT and , clinical lead for the stroke service, felt it was clinically appropriate for Geoffrey to be transferred to Phoenix ward at RCHT. At that time, however, no beds were available on the ward.
Shortly thereafter, a request was made for a rehabilitation bed at Camborne & Redruth Community Hospital. Again, no bed was available.
Geoffrey’s presentation fluctuated. In early July, it was felt it would no longer be in his best interests to be transferred to CRCH due to low mood. On 30 July, approximately six weeks after admission to WCH, Information Classification: CONTROLLED Geoffrey was transferred to Penhallow reablement unit - on the family’s evidence, without prior discussion with them. He was seen by a stroke nurse on 5 August who felt Geoffrey’s needs were greater than the unit could meet. He was transferred the same day to Royal Cornwall Hospital. Two safeguarding referrals were made which culminated with a referral to the police.
On 15 August, Geoffrey was transferred to Poldhu Nursing Home where he remained until he died. The police have confirmed no criminal offence has been disclosed. The safeguarding investigations appear to have been closed after it was established he was in a suitable Home.
Shortly thereafter, a request was made for a rehabilitation bed at Camborne & Redruth Community Hospital. Again, no bed was available.
Geoffrey’s presentation fluctuated. In early July, it was felt it would no longer be in his best interests to be transferred to CRCH due to low mood. On 30 July, approximately six weeks after admission to WCH, Information Classification: CONTROLLED Geoffrey was transferred to Penhallow reablement unit - on the family’s evidence, without prior discussion with them. He was seen by a stroke nurse on 5 August who felt Geoffrey’s needs were greater than the unit could meet. He was transferred the same day to Royal Cornwall Hospital. Two safeguarding referrals were made which culminated with a referral to the police.
On 15 August, Geoffrey was transferred to Poldhu Nursing Home where he remained until he died. The police have confirmed no criminal offence has been disclosed. The safeguarding investigations appear to have been closed after it was established he was in a suitable Home.
Action Should Be Taken
The inquest was told that an identified increase in the mortality rates of stroke patients in Cornwall has been identified and that an action plan has been drawn up to address the issue. None of the plan’s detail was available for the inquest.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.