Tracey Oldfield
PFD Report
All Responded
Ref: 2025-0578
All 1 response received
· Deadline: 6 Jan 2026
Coroner's Concerns (AI summary)
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
View full coroner's concerns
The MATTERS OF CONCERN have largely been identified and addressed by a Patient Safety Incident Investigation report that was available to the court. A number of changes and improvements have already been made or will be undertaken, for example, when the Trust’s IT systems are upgraded.
One point that did not appear to have been fully resolved, however, centred on the need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.
On the facts of this case, Tracey was prescribed insulin when the family informed clinical staff she had a diagnosis of diabetes. Her pain relief was not prescribed at the same time, however, and as she became more uncomfortable after the nerve block used intra-operatively wore off, this resulted in her being prescribed opiates (inappropriately) rather than her usual Gabapentin.
There was debate at the inquest as to who would be best placed to prepare the prescription and when. Matron thought it could be done by an anaesthetist who would be reviewing the patient pre-operatively in any event. (Head of Patient Safety) felt it could be better done by a junior doctor when a patient was admitted and clerked in. On the facts of this case, Tracey was not seen by a junior doctor (other than to have an insulin prescription) and was not formally clerked in. Information Classification: CONTROLLED
One point that did not appear to have been fully resolved, however, centred on the need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.
On the facts of this case, Tracey was prescribed insulin when the family informed clinical staff she had a diagnosis of diabetes. Her pain relief was not prescribed at the same time, however, and as she became more uncomfortable after the nerve block used intra-operatively wore off, this resulted in her being prescribed opiates (inappropriately) rather than her usual Gabapentin.
There was debate at the inquest as to who would be best placed to prepare the prescription and when. Matron thought it could be done by an anaesthetist who would be reviewing the patient pre-operatively in any event. (Head of Patient Safety) felt it could be better done by a junior doctor when a patient was admitted and clerked in. On the facts of this case, Tracey was not seen by a junior doctor (other than to have an insulin prescription) and was not formally clerked in. Information Classification: CONTROLLED
Responses
Action Planned
A multidisciplinary group has been established to advise on strengthening governance for prescribing medications following unexpected hospital admission after day case surgery, with implementation planned by May 2026. Four workstreams have been identified, and an audit is planned for September 2026. (AI summary)
A multidisciplinary group has been established to advise on strengthening governance for prescribing medications following unexpected hospital admission after day case surgery, with implementation planned by May 2026. Four workstreams have been identified, and an audit is planned for September 2026. (AI summary)
View full response
Dear Mr Cox,
Re: The Late Tracey Oldfield – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 11 November 2025 and received on the 13 November 2025. This was issued following the inquest into the death of Tracey Oldfield which concluded on 10 November 2025. I would like to take this opportunity to express my sincerest condolences to the family of Tracey Oldfield for their loss. During the inquest, the evidence revealed a matter giving rise to concern. Which is as follows:
• How surgical day case patients who are admitted at short notice have their usual medications prescribed in a timely fashion. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Response:
1. A multidisciplinary group of relevant clinicians has been established to advise strengthening existing governance related to safe, accurate and timely prescribing of a patient’s regular medications following unexpected hospital admission following Day Case Surgery. It will report to Clinical Effectiveness Group on 25th March 2026 for action plan sign off prior to implementation by 27th May 2026.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ
2. The following 4 workstreams have been identified:
i. Identify the systems used which alert all day surgery patients with an unplanned inpatient admission due to unexpected change in clinical condition including location, reason for admission and responsible consultant.
ii. Ensure all current patient data platforms triangulate and provide accurate information on this patient subset to the site co-ordination office, responsible senior and resident doctors. Influence the planning and implementation of the new integrated clinical care platform, eCare to further strengthen tracking these patients.
iii. Ensure a responsible consultant is identified and aware of the patient admission at the time of admission. This consultant can either be the operating clinician, or the relevant specialty on-call consultant if the admission occurs out of hours.
iv. Strengthen resident doctor and nursing staff training and awareness of the requirement to conduct a thorough documented clinical review (clerking) of all day surgery patients admitted as an inpatient post operatively due to unexpected clinical change.
v. Ensure medical and nursing staff adhere to existing pharmacy prescribing policies including medicines reconciliation with a focus on ‘high risk medications’ such as insulin, opioids, anticoagulants, psychotropics and immunosuppressants.
3. Following implementation, we will audit postoperative prescribing of all patients admitted as inpatients following day case surgery against each of the five workstream recommendations. This audit will be commissioned and monitored by the Clinical Effectiveness Group with an expected completion date in September 2026. Any learning and further work identified will be reviewed by the group 25th November 2026.
4. Immediate Response pending implementation of the above workstreams: The findings of the PSR2 and PFD report and response will be shared with Care group leadership and clinical governance teams at Patient Safety Incident Review Oversight Group (PSIROG), with a request to cascade to all clinical specialty groups and teams providing day surgery services to review and strengthen current practice to ensure patients unexpectedly admitted following day surgery under go full clerking by a resident doctor with review of regular medications with appropriate senior oversight. I hope that this letter provides both you and Tracey’s family with assurance that the Trust has taken seriously the concern you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Re: The Late Tracey Oldfield – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 11 November 2025 and received on the 13 November 2025. This was issued following the inquest into the death of Tracey Oldfield which concluded on 10 November 2025. I would like to take this opportunity to express my sincerest condolences to the family of Tracey Oldfield for their loss. During the inquest, the evidence revealed a matter giving rise to concern. Which is as follows:
• How surgical day case patients who are admitted at short notice have their usual medications prescribed in a timely fashion. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern. Response:
1. A multidisciplinary group of relevant clinicians has been established to advise strengthening existing governance related to safe, accurate and timely prescribing of a patient’s regular medications following unexpected hospital admission following Day Case Surgery. It will report to Clinical Effectiveness Group on 25th March 2026 for action plan sign off prior to implementation by 27th May 2026.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ
2. The following 4 workstreams have been identified:
i. Identify the systems used which alert all day surgery patients with an unplanned inpatient admission due to unexpected change in clinical condition including location, reason for admission and responsible consultant.
ii. Ensure all current patient data platforms triangulate and provide accurate information on this patient subset to the site co-ordination office, responsible senior and resident doctors. Influence the planning and implementation of the new integrated clinical care platform, eCare to further strengthen tracking these patients.
iii. Ensure a responsible consultant is identified and aware of the patient admission at the time of admission. This consultant can either be the operating clinician, or the relevant specialty on-call consultant if the admission occurs out of hours.
iv. Strengthen resident doctor and nursing staff training and awareness of the requirement to conduct a thorough documented clinical review (clerking) of all day surgery patients admitted as an inpatient post operatively due to unexpected clinical change.
v. Ensure medical and nursing staff adhere to existing pharmacy prescribing policies including medicines reconciliation with a focus on ‘high risk medications’ such as insulin, opioids, anticoagulants, psychotropics and immunosuppressants.
3. Following implementation, we will audit postoperative prescribing of all patients admitted as inpatients following day case surgery against each of the five workstream recommendations. This audit will be commissioned and monitored by the Clinical Effectiveness Group with an expected completion date in September 2026. Any learning and further work identified will be reviewed by the group 25th November 2026.
4. Immediate Response pending implementation of the above workstreams: The findings of the PSR2 and PFD report and response will be shared with Care group leadership and clinical governance teams at Patient Safety Incident Review Oversight Group (PSIROG), with a request to cascade to all clinical specialty groups and teams providing day surgery services to review and strengthen current practice to ensure patients unexpectedly admitted following day surgery under go full clerking by a resident doctor with review of regular medications with appropriate senior oversight. I hope that this letter provides both you and Tracey’s family with assurance that the Trust has taken seriously the concern you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Sent To
- Royal Cornwall Hospital
Response Status
Linked responses
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56-Day Deadline
6 Jan 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 10/11/25, I concluded the inquest into the death of Tracey Oldfield who died in RCHT on 24/10/24 at the age of 56.
I recorded the cause of death as: 1a) Hypoxic ischaemic encephalopathy and aspiration pneumonia; 1b) Cardiac arrest; 1c) Combined effects of opiate-mediated respiratory depression and an absence of CPAP respiratory support for obstructive sleep apnoea. II) End-stage renal failure complicating insulin-dependent Type 2 Diabetes Mellitus, valvular and hypertensive heart disease.
I recorded a conclusion that Tracy died from complications that developed following an elective procedure resulting in an unanticipated admission into hospital.
I recorded the cause of death as: 1a) Hypoxic ischaemic encephalopathy and aspiration pneumonia; 1b) Cardiac arrest; 1c) Combined effects of opiate-mediated respiratory depression and an absence of CPAP respiratory support for obstructive sleep apnoea. II) End-stage renal failure complicating insulin-dependent Type 2 Diabetes Mellitus, valvular and hypertensive heart disease.
I recorded a conclusion that Tracy died from complications that developed following an elective procedure resulting in an unanticipated admission into hospital.
Circumstances of the Death
Tracey was a 56-year-old lady with a diagnosis of type 2 diabetes mellitus, end-stage renal failure, hypertension, obstructive sleep apnoea and peripheral neuropathy. She had been in receipt of dialysis since 2020. She had a surgical fistula to facilitate treatment, but this needed revision. On 17/10/24, Tracey underwent an elective procedure in this regard as a day case which was technically unremarkable. Post-operatively, however, she was found to have low oxygen saturations and low blood sugars. She was admitted. Ordinarily, Tracey slept with CPAP ventilation due to her sleep apnoea. Information Classification: CONTROLLED She had not brought her device into hospital with her and although documented in her admission records, this was not handed over to ward staff. Additionally, Tracey was not prescribed her normal medications but instead received a standard bundle of medication for surgical patients. This included two doses of oramorph for pain relief where opiate medication was contra-indicated for a patient in end-stage renal failure. The oramorph caused Tracey to become drowsy and unresponsive which was exacerbated by the lack of CPAP ventilation. There was also no senior medical review resulting in a lost opportunity to remedy the oversights. Tracey suffered a cardiac arrest on 19/10/24 and suffered a hypoxic brain injury. She deteriorated and died in Royal Cornwall Hospital on 24/10/24
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.