Mary Fitzpatrick
PFD Report
All Responded
Ref: 2025-0435
All 1 response received
· Deadline: 15 Oct 2025
Coroner's Concerns (AI summary)
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in an elderly patient.
View full coroner's concerns
As you will see from the Record of Inquest attached, I made a finding that death would not have occurred when it did, had it not been for the 23 January admission to hospital, the development of the pressure sore, and the failure properly to treat that pressure sore.
1. It is well recognised that the admission of an elderly person to hospital can be risky and should only be undertaken if really necessary. These days, a long wait on a hospital trolley is predictable. Even without that, the elderly are known often to decondition quickly.
At inquest I accepted the evidence of Mrs Fitzpatrick’s family that the reality of her admission to the Whittington on 23 January 2025 was that it was undertaken because there was only one nurse attending her on that day and this nurse felt she could not transfer this small, elderly lady alone with the aids that were available.
2. The district nurses did not visit to dress the sacral wound with appropriate frequency. Sometimes they attended as planned, but sometimes they did not attend and sometimes they attended but did not change the sacral dressing. It remains unclear to me why that was so. The only explanation I was given was that they were probably “thin on the ground”.
3. When I took evidence from the deputy manager of the Islington Central district nursing team, I was very forcibly struck by the lack of reflection undertaken since Mrs Fitzpatrick’s death, about the district nursing care, even when preparing to give evidence at inquest. The deputy manager was poorly prepared for inquest, appeared to have an inadequate understanding of what was required of her giving evidence, had not acquainted herself with some basic elements of the medical records and, whilst in the witness box, changed her mind about what home visits had been undertaken depending upon who asked her the question.
She steadfastly refused to acknowledge gaps in care despite glaring evidence to the contrary, and when this was brought to her attention she simply stopped answering.
It is difficult to see how a trust can learn and improve care if there is no serious consideration of why there was a poor outcome.
Even the letter of apology sent to Mrs Fitzpatrick’s family was offered to her daughter in an offhand way during a very short telephone call. When giving evidence, the deputy manager seemed to be in difficulty understanding what an apology is, naming this a letter of apology but in essence describing a letter of sympathy, emphasising that it was not an admission that the trust had done anything wrong. I still do not have a proper understanding of what such a letter was meant to achieve. Much more importantly, it seemed to me that Mrs Fitzpatrick’s family do not have a proper understanding of what this letter was meant to achieve. They did not seem comforted by it.
1. It is well recognised that the admission of an elderly person to hospital can be risky and should only be undertaken if really necessary. These days, a long wait on a hospital trolley is predictable. Even without that, the elderly are known often to decondition quickly.
At inquest I accepted the evidence of Mrs Fitzpatrick’s family that the reality of her admission to the Whittington on 23 January 2025 was that it was undertaken because there was only one nurse attending her on that day and this nurse felt she could not transfer this small, elderly lady alone with the aids that were available.
2. The district nurses did not visit to dress the sacral wound with appropriate frequency. Sometimes they attended as planned, but sometimes they did not attend and sometimes they attended but did not change the sacral dressing. It remains unclear to me why that was so. The only explanation I was given was that they were probably “thin on the ground”.
3. When I took evidence from the deputy manager of the Islington Central district nursing team, I was very forcibly struck by the lack of reflection undertaken since Mrs Fitzpatrick’s death, about the district nursing care, even when preparing to give evidence at inquest. The deputy manager was poorly prepared for inquest, appeared to have an inadequate understanding of what was required of her giving evidence, had not acquainted herself with some basic elements of the medical records and, whilst in the witness box, changed her mind about what home visits had been undertaken depending upon who asked her the question.
She steadfastly refused to acknowledge gaps in care despite glaring evidence to the contrary, and when this was brought to her attention she simply stopped answering.
It is difficult to see how a trust can learn and improve care if there is no serious consideration of why there was a poor outcome.
Even the letter of apology sent to Mrs Fitzpatrick’s family was offered to her daughter in an offhand way during a very short telephone call. When giving evidence, the deputy manager seemed to be in difficulty understanding what an apology is, naming this a letter of apology but in essence describing a letter of sympathy, emphasising that it was not an admission that the trust had done anything wrong. I still do not have a proper understanding of what such a letter was meant to achieve. Much more importantly, it seemed to me that Mrs Fitzpatrick’s family do not have a proper understanding of what this letter was meant to achieve. They did not seem comforted by it.
Responses
Action Taken
Whittington Health NHS Trust has devised new procedures to ensure all patient deaths under their care in community services are formally reviewed for learning. A new Duty of Candour proforma has been developed to accurately capture both professional and written Duty of Candour. (AI summary)
Whittington Health NHS Trust has devised new procedures to ensure all patient deaths under their care in community services are formally reviewed for learning. A new Duty of Candour proforma has been developed to accurately capture both professional and written Duty of Candour. (AI summary)
View full response
Dear Senior Coroner Hassell,
Thank you for your Regulation 28 report dated 20 August 2025 concerning the very sad death of Mrs Mary Fitzpatrick. On behalf of Whittington Health NHS Trust, I wish again to express our condolences to her family. We take the concerns you have raised extremely seriously. This response sets out the actions we have already taken and those we are committed to undertaking to ensure learning, improvement, and prevention of similar future deaths.
1. Circumstances of Hospital Admission and Risk of Deconditioning We recognise the risks associated with hospital admission for frail elderly patients, particularly where transfer occurs due to staffing limitations in community settings. We accept that in this instance, the care of Mrs Fitzpatrick fell short in a number of ways.
Chief Medical Officer Deputy Chief Executive Medical Directorate Jenner Building Magdala Avenue London N19 5NF
Whittington Health NHS Trust
Helping local people live longer healthier lives
• Missed leg ulcer management: On the balance of probabilities, the deterioration of her leg ulcers was linked to the lack of treatment following the cancellations of scheduled appointments on 18, 20, 21, and 22 January 2025. As there was no evidence of mental impairment at that time, a mental capacity assessment was not carried out with regards to the decision to cancel visits, and she was presumed to have capacity.
• Time in the Emergency Department: Mrs Fitzpatrick spent 40 hours in the Emergency Department, due to the department being under extreme pressure. some of this time in a temporary escalation space. We accept this falls short of the standard of care we would aspire to provide. Mrs Fitzpatrick arrived in Triage at 20:27. She was then transferred to a trolley and initially cared for in a temporary escalation space. While we work to avoid care in temporary escalation spaces, we have a standard operating procedure to set out the care which should carry on in non-clinical areas when necessary. At
23.45 Mrs Fitzpatrick was moved into a cubicle in the Majors area. She was transferred to a bed at 03:33 on 24/01/25. She was placed on a standard foam pressure relieving mattress at this time. When she was moved to the ward she was placed on a pneumatic pressure relieving mattress.
• Pressure sore identification and management: Her pressure areas were reviewed and documented within 2 hours of arrival and this identified her pressure sore. She was subsequently admitted and had further reviews, and the correct equipment and care plans were instituted.
• Risk factors: The risk of pressure sores was increased due to Mrs Fitzpatrick’s frailty and incontinence. We regret that she developed additional grade 2 sores during her hospital admission. Action Plan: A Quality improvement Project is in progress in our ED to monitor adherence to Pressure Ulcer Prevention and Management Policy as ED acknowledge that elderly patients spend longer in ED due to the complexity of their care. The standard is that all at risk patients will have their pressure areas reviewed within one hour of admission, and that prevention management will be instituted within four hours. The project is carrying out spot check audits of a 10-point check list for 10 patients per week. The results will be presented to will be presented Emergency and Integrated Medicine Quality Committee on 20th November 2025. Our Trust Policy governing care in temporary escalation spaces has been appended for reference.
Whittington Health NHS Trust
Helping local people live longer healthier lives
2. Frequency and Quality of District Nursing Visits We acknowledge the coroner’s concern regarding the frequency and appropriateness of district nursing visits and dressing changes. A review of Mrs Fitzpatrick’s records has allowed us to reconstruct the chronology of community nursing input following her hospital discharge:
• There were 2 missed opportunities for dressing changes on 5 February (visit not allocated) and 10 February (Mrs Fitzpatrick declined to be moved by the two staff members attending so dressings were not completed).
• Despite these missed visits, there was regular documentation of wound progression, escalation to the GP, referral to Tissue Viability, and repeated advice regarding hospital admission.
• When the pressure ulcers were found to have deteriorated. A Safeguarding Alert was raised as the pressure relieving mattress had been found to be switched off with no explanation on 24 February 2025.
• Staffing during this period was affected by long-term sickness (1 staff member >4 months) and annual leave (2 staff members). However agency and bank nurses were used to maintain service cover, and a bank nurse undertook the joint visit on 8 February.
• Double-handed visits were provided where identified as necessary from 7 February onwards.
• We apologise that this information was not fully accessible to the coroner during the inquest Action Plan:
• Ensure daily visits allocations are individualised to meet the patients’ Pressure Ulcer (PU) management need by the duty manager, with monthly oversight from Service Lead.
• Timely referral to Tissue Viability Nurse (TVN), adherence with TVN recommendations, and progression of pressure ulcer management improvement plan are to be built into new quarterly audit cycle, and reviewed at divisional quality meeting.
• Shared learning from PU incidents will be ensured via weekly divisional pressure ulcer shared learning meetings.
Whittington Health NHS Trust
Helping local people live longer healthier lives
• A trial of visit allocation software (Docabode) is in progress in the Urgent response team and is intended to minimise travel time and maximise time for visits. If successful it will be trialled in District Nursing
3. Reflection, Learning, and Preparation for Inquests We acknowledge the coroner’s concern that there was insufficient reflection on the quality of district nursing care provided to Mrs Fitzpatrick, both during her deterioration and in preparation for the inquest. We accept that the deputy manager who attended court was not adequately prepared to give evidence, which fell below the expected standard. We also recognise that our communication with Mrs Fitzpatrick’s family—both in person and in writing—did not provide the clarity, explanation, or candour they deserved, and that this contributed to their distress. Action Plan: Mortality review process: Current mortality review processes are largely designed to cover inpatients. New procedures are being devised to ensure all patient deaths under our care in the community services we run are formally reviewed for learning. Learning from Death: incidents and feedback, inquest outcomes and PFD notices will continue to be shared with staff at meetings. In addition, they will also be cascaded to all staff working in community services. Increase in support and training for staff involved in writing statements and attending the coroner’s court: This will also include advice to ensure that staff will not only cover the care that was delivered by themselves, but provide an overarching statement covering the care delivered as a whole by the Trust. Support will be given by the legal services team. The Trust is reviewing the seniority of staff attending coroner’s court to provide the court with the most useful and informative evidence. In addition to this, new guidance for staff preparing for inquests will be circulated by the Associate Medical Director for learning from deaths, in coordination with the legal department. New proforma: A new Duty of Candour proforma has been developed to accurately capture both professional and written Duty of Candour, ensuring documentation is clear and complete. This will better enable tracking and audit of statutory duty of candour across the trust. We expect to have this completed by December 2025, with the results presented to the Quality Governance Committee.
Whittington Health NHS Trust
Helping local people live longer healthier lives Duty of Candour audit and training: Ongoing audit and refresher training are being introduced to strengthen understanding of and compliance with Duty of Candour. Levels of completion of training will be monitored by the patient safety team, and the results presented to the Quality Governance Committee quarterly.
Chief Medical Officer
Thank you for your Regulation 28 report dated 20 August 2025 concerning the very sad death of Mrs Mary Fitzpatrick. On behalf of Whittington Health NHS Trust, I wish again to express our condolences to her family. We take the concerns you have raised extremely seriously. This response sets out the actions we have already taken and those we are committed to undertaking to ensure learning, improvement, and prevention of similar future deaths.
1. Circumstances of Hospital Admission and Risk of Deconditioning We recognise the risks associated with hospital admission for frail elderly patients, particularly where transfer occurs due to staffing limitations in community settings. We accept that in this instance, the care of Mrs Fitzpatrick fell short in a number of ways.
Chief Medical Officer Deputy Chief Executive Medical Directorate Jenner Building Magdala Avenue London N19 5NF
Whittington Health NHS Trust
Helping local people live longer healthier lives
• Missed leg ulcer management: On the balance of probabilities, the deterioration of her leg ulcers was linked to the lack of treatment following the cancellations of scheduled appointments on 18, 20, 21, and 22 January 2025. As there was no evidence of mental impairment at that time, a mental capacity assessment was not carried out with regards to the decision to cancel visits, and she was presumed to have capacity.
• Time in the Emergency Department: Mrs Fitzpatrick spent 40 hours in the Emergency Department, due to the department being under extreme pressure. some of this time in a temporary escalation space. We accept this falls short of the standard of care we would aspire to provide. Mrs Fitzpatrick arrived in Triage at 20:27. She was then transferred to a trolley and initially cared for in a temporary escalation space. While we work to avoid care in temporary escalation spaces, we have a standard operating procedure to set out the care which should carry on in non-clinical areas when necessary. At
23.45 Mrs Fitzpatrick was moved into a cubicle in the Majors area. She was transferred to a bed at 03:33 on 24/01/25. She was placed on a standard foam pressure relieving mattress at this time. When she was moved to the ward she was placed on a pneumatic pressure relieving mattress.
• Pressure sore identification and management: Her pressure areas were reviewed and documented within 2 hours of arrival and this identified her pressure sore. She was subsequently admitted and had further reviews, and the correct equipment and care plans were instituted.
• Risk factors: The risk of pressure sores was increased due to Mrs Fitzpatrick’s frailty and incontinence. We regret that she developed additional grade 2 sores during her hospital admission. Action Plan: A Quality improvement Project is in progress in our ED to monitor adherence to Pressure Ulcer Prevention and Management Policy as ED acknowledge that elderly patients spend longer in ED due to the complexity of their care. The standard is that all at risk patients will have their pressure areas reviewed within one hour of admission, and that prevention management will be instituted within four hours. The project is carrying out spot check audits of a 10-point check list for 10 patients per week. The results will be presented to will be presented Emergency and Integrated Medicine Quality Committee on 20th November 2025. Our Trust Policy governing care in temporary escalation spaces has been appended for reference.
Whittington Health NHS Trust
Helping local people live longer healthier lives
2. Frequency and Quality of District Nursing Visits We acknowledge the coroner’s concern regarding the frequency and appropriateness of district nursing visits and dressing changes. A review of Mrs Fitzpatrick’s records has allowed us to reconstruct the chronology of community nursing input following her hospital discharge:
• There were 2 missed opportunities for dressing changes on 5 February (visit not allocated) and 10 February (Mrs Fitzpatrick declined to be moved by the two staff members attending so dressings were not completed).
• Despite these missed visits, there was regular documentation of wound progression, escalation to the GP, referral to Tissue Viability, and repeated advice regarding hospital admission.
• When the pressure ulcers were found to have deteriorated. A Safeguarding Alert was raised as the pressure relieving mattress had been found to be switched off with no explanation on 24 February 2025.
• Staffing during this period was affected by long-term sickness (1 staff member >4 months) and annual leave (2 staff members). However agency and bank nurses were used to maintain service cover, and a bank nurse undertook the joint visit on 8 February.
• Double-handed visits were provided where identified as necessary from 7 February onwards.
• We apologise that this information was not fully accessible to the coroner during the inquest Action Plan:
• Ensure daily visits allocations are individualised to meet the patients’ Pressure Ulcer (PU) management need by the duty manager, with monthly oversight from Service Lead.
• Timely referral to Tissue Viability Nurse (TVN), adherence with TVN recommendations, and progression of pressure ulcer management improvement plan are to be built into new quarterly audit cycle, and reviewed at divisional quality meeting.
• Shared learning from PU incidents will be ensured via weekly divisional pressure ulcer shared learning meetings.
Whittington Health NHS Trust
Helping local people live longer healthier lives
• A trial of visit allocation software (Docabode) is in progress in the Urgent response team and is intended to minimise travel time and maximise time for visits. If successful it will be trialled in District Nursing
3. Reflection, Learning, and Preparation for Inquests We acknowledge the coroner’s concern that there was insufficient reflection on the quality of district nursing care provided to Mrs Fitzpatrick, both during her deterioration and in preparation for the inquest. We accept that the deputy manager who attended court was not adequately prepared to give evidence, which fell below the expected standard. We also recognise that our communication with Mrs Fitzpatrick’s family—both in person and in writing—did not provide the clarity, explanation, or candour they deserved, and that this contributed to their distress. Action Plan: Mortality review process: Current mortality review processes are largely designed to cover inpatients. New procedures are being devised to ensure all patient deaths under our care in the community services we run are formally reviewed for learning. Learning from Death: incidents and feedback, inquest outcomes and PFD notices will continue to be shared with staff at meetings. In addition, they will also be cascaded to all staff working in community services. Increase in support and training for staff involved in writing statements and attending the coroner’s court: This will also include advice to ensure that staff will not only cover the care that was delivered by themselves, but provide an overarching statement covering the care delivered as a whole by the Trust. Support will be given by the legal services team. The Trust is reviewing the seniority of staff attending coroner’s court to provide the court with the most useful and informative evidence. In addition to this, new guidance for staff preparing for inquests will be circulated by the Associate Medical Director for learning from deaths, in coordination with the legal department. New proforma: A new Duty of Candour proforma has been developed to accurately capture both professional and written Duty of Candour, ensuring documentation is clear and complete. This will better enable tracking and audit of statutory duty of candour across the trust. We expect to have this completed by December 2025, with the results presented to the Quality Governance Committee.
Whittington Health NHS Trust
Helping local people live longer healthier lives Duty of Candour audit and training: Ongoing audit and refresher training are being introduced to strengthen understanding of and compliance with Duty of Candour. Levels of completion of training will be monitored by the patient safety team, and the results presented to the Quality Governance Committee quarterly.
Chief Medical Officer
Sent To
- Chief Executive Whittington Health NHS Trust Whittington Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
15 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 26 March 2025, one of my assistant coroners, Harry Lambert, commenced an investigation into the death of Mary Fitzpatrick aged 86 years. The investigation concluded at the end of the inquest yesterday. I made a narrative determination at inquest, which I attach.
Mrs Fitzpatrick’s medical cause of death was:
1a aspiration pneumonia 1b dysphagia 1c frailty sacral pressure sore
Mrs Fitzpatrick’s medical cause of death was:
1a aspiration pneumonia 1b dysphagia 1c frailty sacral pressure sore
Circumstances of the Death
Mrs Fitzpatrick was discharged from the Whittington Hospital on 29 January 2025 and was then treated by the Islington Central district nursing team from Whittington Health.
Her sacral pressure sore was assessed as a category 2 on 1 February. By 24 February it was a category 4 – a gaping, open wound. It forced her readmission to hospital on 27 February, at which point she deconditioned and then died.
Her sacral pressure sore was assessed as a category 2 on 1 February. By 24 February it was a category 4 – a gaping, open wound. It forced her readmission to hospital on 27 February, at which point she deconditioned and then died.
Copies Sent To
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.