Kore Padgett
PFD Report
All Responded
Ref: 2025-0441
All 1 response received
· Deadline: 23 Oct 2025
Coroner's Concerns (AI summary)
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.
View full coroner's concerns
i) The absence of training for staff on the ward in respect of the correct fitting of a hard collar; ii) The absence of communication by the treating clinicians with the neurosurgical team at Leeds in respect of treatment options for Kore given the significant impact that the wearing of the collar was having on Kore with the development of pressure sores, difficulties with her swallow and increasing risks of aspiration. iii) The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed. iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.
Responses
Action Planned
Calderdale and Huddersfield NHS Foundation Trust will implement a Trust-wide training program for applying and managing hard collars, led by senior clinicians, with sessions scheduled for December 2025 and January 2026. They are also developing a Standard Operating Procedure (SOP) for collar initiation and management to be implemented by the end of January 2026, and care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). (AI summary)
Calderdale and Huddersfield NHS Foundation Trust will implement a Trust-wide training program for applying and managing hard collars, led by senior clinicians, with sessions scheduled for December 2025 and January 2026. They are also developing a Standard Operating Procedure (SOP) for collar initiation and management to be implemented by the end of January 2026, and care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). (AI summary)
View full response
Dear Ms Keighley,
Re: Prevention of Future Deaths Report – Ms Kore Padgett
Thank you for your Regulation 28 report following the inquest into the death of Ms Kore Elizabeth Padgett. Calderdale and Huddersfield NHS Foundation Trust once again extends its sincere condolences to Ms Padgett’s family and acknowledges the concerns raised in your report.
In response, a comprehensive multi-disciplinary team (MDT) review was convened on 29 September 2025 to examine the issues identified and to ensure that appropriate learning and improvement actions are taken. The review included senior clinical, governance, legal, and operational stakeholders across relevant specialties, with input from Leeds Teaching Hospitals where neurosurgical care was involved.
The MDT focused on four key areas of concern raised in the PFD:
1. Staff training in the application of hard collars
2. Communication with the neurosurgical team regarding treatment options
3. Consideration of risks versus benefits of collar use and informed consent
4. Ward-level communication and multidisciplinary decision-making
MDT Conclusion
The review highlighted that although specialist teams like Orthotics and Physiotherapy follow well-established training protocols, there is no unified Trust- wide competency framework for the application of hard collars among all relevant staff groups. As a result, staff often depend on informal experience, which can contribute to variability in practice.
The review also identified missed opportunities for collaborative decision-making and escalation regarding collar-related complications. Documentation of MDT discussions, patient preferences, and risk-benefit considerations were found to be insufficient, limiting the ability to demonstrate informed consent and person-centred care.
Furthermore, the absence of a structured escalation pathway and designated ward for cervical spine injury management contributed to fragmented communication and delayed reassessment of treatment plans.
Safety Improvement Actions
The Trust has taken proactive and comprehensive steps to ensure the safe and consistent care of patients with cervical spine injuries. In response to concerns raised, we have developed a robust clinical pathway to guide admission, and treatment within dedicated acute orthopaedic wards. This pathway ensures that patients are consistently placed in clinical areas with the appropriate skills and resources to support all aspects of their care. The pathway also incorporates coordinated support from ortho-geriatricians and the multidisciplinary team (MDT). An ongoing audit is evaluating the admitting ward allocation, treatment, and patient outcomes. This work is led by , Consultant and Divisional Director for Surgery and Anaesthetics, and Consultant and Clinical Director for Acute Medicine, and is on track for delivery by November 2025.
To support this pathway, CHFT guidance and protocols are being revised to provide clear escalation processes for clinical advice, complications and neurosurgical liaison and involvement relating to cervical spine injury. These revisions are being led by Dr , Consultant in Care of the Elderly, and will ensure that patients are managed consistently in line with updated standards. This work is also scheduled for completion by November 2025 and is progressing as planned.
Following implementation of the pathway and protocols, audits will be conducted at 1, 3, and 6 months to assess adherence to best practice and identify any areas requiring further optimisation. The frequency of future audits will be reviewed based on the findings and determined by whether additional improvements are needed.
Patients with cervical spine injuries who require management with a neck collar are being admitted to Wards 19 and 21 at Huddersfield Royal Infirmary (acute
orthopaedic wards) to support continuity of care and operational efficiency. To ensure safe and effective treatment, competency-based training will be provided to all clinical professionals involved in their care, including Registered Nurses, Allied Health Professionals, and substantive ward based Medical Staff. Led by (Senior Clinical Orthotist) and (Outpatient Therapy Services Manager), the training focuses on validated competency in the application, monitoring, and management of neck collars. Two sessions have been scheduled for Ward 19 staff in December 2025, with further sessions planned for Ward 21 staff in January 2026. Compliance will be monitored through annual audits, beginning one month after training implementation. The initiative remains on track for completion by the end of January 2026.
A Standard Operating Procedure (SOP) for collar initiation and management is also being developed. This SOP will include guidance on consent, risk versus benefit, informed decision-making, collaborative input from the neurosurgical team, and clear escalation protocols. Led by Dr , Matron for Surgery and Anaesthetics, the SOP will be embedded within the competency framework and is scheduled for implementation by the end of January 2026.
In addition, CHFT is further embedding person-centred care principles to support informed consent when a patient has a collar in place. Led by , Associate Director of Nursing for Surgery and Anaesthetics and Matron , care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). This initiative will be monitored through EPR audits and Quality Assurance Leadership walk rounds and is scheduled for completion by January 2026.
CHFT remains committed to delivering safe, consistent, and person-centred care for patients with cervical spine injuries. All actions are progressing within agreed timelines, with appropriate governance and audit mechanisms in place. We are confident that these measures will prevent future harm and ensure high standards of care across our services.
Re: Prevention of Future Deaths Report – Ms Kore Padgett
Thank you for your Regulation 28 report following the inquest into the death of Ms Kore Elizabeth Padgett. Calderdale and Huddersfield NHS Foundation Trust once again extends its sincere condolences to Ms Padgett’s family and acknowledges the concerns raised in your report.
In response, a comprehensive multi-disciplinary team (MDT) review was convened on 29 September 2025 to examine the issues identified and to ensure that appropriate learning and improvement actions are taken. The review included senior clinical, governance, legal, and operational stakeholders across relevant specialties, with input from Leeds Teaching Hospitals where neurosurgical care was involved.
The MDT focused on four key areas of concern raised in the PFD:
1. Staff training in the application of hard collars
2. Communication with the neurosurgical team regarding treatment options
3. Consideration of risks versus benefits of collar use and informed consent
4. Ward-level communication and multidisciplinary decision-making
MDT Conclusion
The review highlighted that although specialist teams like Orthotics and Physiotherapy follow well-established training protocols, there is no unified Trust- wide competency framework for the application of hard collars among all relevant staff groups. As a result, staff often depend on informal experience, which can contribute to variability in practice.
The review also identified missed opportunities for collaborative decision-making and escalation regarding collar-related complications. Documentation of MDT discussions, patient preferences, and risk-benefit considerations were found to be insufficient, limiting the ability to demonstrate informed consent and person-centred care.
Furthermore, the absence of a structured escalation pathway and designated ward for cervical spine injury management contributed to fragmented communication and delayed reassessment of treatment plans.
Safety Improvement Actions
The Trust has taken proactive and comprehensive steps to ensure the safe and consistent care of patients with cervical spine injuries. In response to concerns raised, we have developed a robust clinical pathway to guide admission, and treatment within dedicated acute orthopaedic wards. This pathway ensures that patients are consistently placed in clinical areas with the appropriate skills and resources to support all aspects of their care. The pathway also incorporates coordinated support from ortho-geriatricians and the multidisciplinary team (MDT). An ongoing audit is evaluating the admitting ward allocation, treatment, and patient outcomes. This work is led by , Consultant and Divisional Director for Surgery and Anaesthetics, and Consultant and Clinical Director for Acute Medicine, and is on track for delivery by November 2025.
To support this pathway, CHFT guidance and protocols are being revised to provide clear escalation processes for clinical advice, complications and neurosurgical liaison and involvement relating to cervical spine injury. These revisions are being led by Dr , Consultant in Care of the Elderly, and will ensure that patients are managed consistently in line with updated standards. This work is also scheduled for completion by November 2025 and is progressing as planned.
Following implementation of the pathway and protocols, audits will be conducted at 1, 3, and 6 months to assess adherence to best practice and identify any areas requiring further optimisation. The frequency of future audits will be reviewed based on the findings and determined by whether additional improvements are needed.
Patients with cervical spine injuries who require management with a neck collar are being admitted to Wards 19 and 21 at Huddersfield Royal Infirmary (acute
orthopaedic wards) to support continuity of care and operational efficiency. To ensure safe and effective treatment, competency-based training will be provided to all clinical professionals involved in their care, including Registered Nurses, Allied Health Professionals, and substantive ward based Medical Staff. Led by (Senior Clinical Orthotist) and (Outpatient Therapy Services Manager), the training focuses on validated competency in the application, monitoring, and management of neck collars. Two sessions have been scheduled for Ward 19 staff in December 2025, with further sessions planned for Ward 21 staff in January 2026. Compliance will be monitored through annual audits, beginning one month after training implementation. The initiative remains on track for completion by the end of January 2026.
A Standard Operating Procedure (SOP) for collar initiation and management is also being developed. This SOP will include guidance on consent, risk versus benefit, informed decision-making, collaborative input from the neurosurgical team, and clear escalation protocols. Led by Dr , Matron for Surgery and Anaesthetics, the SOP will be embedded within the competency framework and is scheduled for implementation by the end of January 2026.
In addition, CHFT is further embedding person-centred care principles to support informed consent when a patient has a collar in place. Led by , Associate Director of Nursing for Surgery and Anaesthetics and Matron , care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). This initiative will be monitored through EPR audits and Quality Assurance Leadership walk rounds and is scheduled for completion by January 2026.
CHFT remains committed to delivering safe, consistent, and person-centred care for patients with cervical spine injuries. All actions are progressing within agreed timelines, with appropriate governance and audit mechanisms in place. We are confident that these measures will prevent future harm and ensure high standards of care across our services.
Sent To
- Calderdale and Huddersfield NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
23 Oct 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
Report Sections
Investigation and Inquest
On 13 November 2024 I commenced an investigation into the death of Kore Elizabeth PADGETT aged 90. The investigation concluded at the end of the inquest on 13 August 2025. The conclusion of the Inquest was that Kore Elizabeth Padgett died as a consequence of naturally occurring disease contributed to by injuries sustained from an accidental fall requiring immobilisation in a hard collar. Kore struggled to tolerate the placement of the collar with it impacting upon her overall health and ability to swallow, placing her at high risk of aspiration and requiring the assistance of a nasogastric tube for feeding.
Circumstances of the Death
In the early hours of the 8th September 2024, Kore Elizabeth Padgett was admitted to Huddersfield Royal Infirmary following an accidental fall down the stairs at home. In the course of her admission, Kore experienced pain in her neck and was subsequently diagnosed with an unstable fracture to her neck, requiring immobilisation in a hard collar. Kore had previously undergone extensive surgery on her neck and given her age and associated frailty, she struggled to tolerate the placement of the collar, which impacted upon her ability to swallow requiring the aid of a nasogastric tube for feeding purposes. The pressure applied by the collar caused Kore to develop three separate pressure sores and she experienced further difficulties as the collar was noted to move whilst in situ, with the staff on the ward being unable to appropriately adjust the collar as they had not be trained to do so. Kore’s care was managed in part through the tissue viability nurses who experienced difficulties in providing pressure relief as a consequence of the ongoing requirement for Kore to wear the collar. On the 2nd October 2024, advice was sought from the neurosurgical team in Leeds as to the ongoing need for the collar and on the basis of the information provided at the time, advice was given to continue with the use of the collar until Kore could be assessed by the neurosurgical team. A request was made for Kore to be assessed within a week but this was not arranged. Kore’s health continued to deteriorate and she went on to develop aspiration pneumonia, requiring chest physiotherapy which was limited by the placement of the collar. No further contact was made with the neurosurgical team to discuss the ongoing effects of the collar on Kore’s physical health and therefore Kore was unable to make an informed decision as to whether or not she wanted to continue wearing the collar or could remove it and accept any associated risks. Kore went on to develop recurrent aspiration pneumonia and on the 23rd October 2024, despite having previous periods of improvement, her condition rapidly deteriorated and she passed away.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.