Susan Clissold
PFD Report
All Responded
Ref: 2025-0325
All 1 response received
· Deadline: 8 Sep 2025
Coroner's Concerns (AI summary)
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.
View full coroner's concerns
1. District nurses were required to attend to Mrs Clissold on a weekly basis. On several occasions they did not attend because they did not have sufficient members of the team available.
2. Evidence was heard that individual cases are becoming more complex involving greater input from the community nursing team and there are an increasing number of patients requiring support.
3. Norfolk Community Health and Care NHS Trust has taken steps to try to ensure there are sufficient staff to attend to patients in the community as required, such as by relocating staff on a temporary basis and prioritising patients.
4. However, evidence was heard they are not able to attend to every appointment as required
2. Evidence was heard that individual cases are becoming more complex involving greater input from the community nursing team and there are an increasing number of patients requiring support.
3. Norfolk Community Health and Care NHS Trust has taken steps to try to ensure there are sufficient staff to attend to patients in the community as required, such as by relocating staff on a temporary basis and prioritising patients.
4. However, evidence was heard they are not able to attend to every appointment as required
Responses
Noted
The Department of Health and Social Care acknowledges the concerns about district nurse numbers but states the responsibility lies with local Integrated Care Boards and NHS trusts, while mentioning a forthcoming 10 Year Workforce Plan. (AI summary)
The Department of Health and Social Care acknowledges the concerns about district nurse numbers but states the responsibility lies with local Integrated Care Boards and NHS trusts, while mentioning a forthcoming 10 Year Workforce Plan. (AI summary)
View full response
Dear Ms Lake,
Thank you for the Regulation 28 report of 27 June 2025 sent to the Secretary of State for Health and Social Care about the death of Susan Elizabeth Clissold. I am replying as the Minister with responsibility for Workforce and I apologise for the delay in doing so.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Clissold’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns about the number of district nurses within the Norfolk area and their capacity to attend to an increasing volume of patients in the community.
Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for the number and quality of district nurses sits with local Integrated Care Boards and NHS trusts. You may find it useful to redirect the Regulation 28 Report to these bodies to get a full and comprehensive response on the matters you have raised.
While the direct responsibility for the quality and number of district nurses sits with local Integrated Care Board and NHS trusts, I would like to assure you that the government recognises the constraints in which the NHS has operated in recent years. That is why this Government will publish a 10 Year Workforce Plan in spring to ensure we have a sufficient and skilled NHS workforce able to provide the right care, at the right time, in the right place. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 27 June 2025 sent to the Secretary of State for Health and Social Care about the death of Susan Elizabeth Clissold. I am replying as the Minister with responsibility for Workforce and I apologise for the delay in doing so.
Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Clissold’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns about the number of district nurses within the Norfolk area and their capacity to attend to an increasing volume of patients in the community.
Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for the number and quality of district nurses sits with local Integrated Care Boards and NHS trusts. You may find it useful to redirect the Regulation 28 Report to these bodies to get a full and comprehensive response on the matters you have raised.
While the direct responsibility for the quality and number of district nurses sits with local Integrated Care Board and NHS trusts, I would like to assure you that the government recognises the constraints in which the NHS has operated in recent years. That is why this Government will publish a 10 Year Workforce Plan in spring to ensure we have a sufficient and skilled NHS workforce able to provide the right care, at the right time, in the right place. I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Sep 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 12 June 2024, I commenced an investigation into the death of Susan Elizabeth CLISSOLD, aged 72. The investigation concluded at the end of the inquest on 23 June 2025. The medical cause of death was: 1a) Sepsis Secondary to Infected Burn and Pressure Sore 1b) Multiple Sclerosis 1c)
2) The conclusion of the inquest was: Natural causes
2) The conclusion of the inquest was: Natural causes
Circumstances of the Death
Mrs Clissold had multiple sclerosis and was registered blind. She had carers four times per day. Mrs Clissold had a pressure sore on her sacrum which district nurses came in to dress. On 29 April 2024, Mrs Clissold scalded her leg with hot coffee and suffered a burn. This too required regular dressing. On 15 May 2024, Mrs Clissold was admitted to Norfolk and Norwich University Hospital with a temperature and low blood pressure and symptoms of infection. She was treated with IV antibiotics and fluids. Mrs Clissold's condition at times improved but then deteriorated. On the morning of 31 May 2024, Mrs Clissold's condition deteriorated and shortly thereafter a referral was made for palliative care. Mrs Clissold died on 9 June 2024.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.