Dear Mr Brenchley

Inquest touching the death of Iris Carter Response to Regulation 28 Report to prevent future deaths

I am writing in response to the Regulation 28 notice issued following the conclusion of the Inquest on 10 April 2025 touching the death of Mrs Carter who died on 8 November 2024 at Birmingham Heartlands Hospital (part of University Hospitals Birmingham NHS Foundation Trust (UHB)).

We have carefully considered the concerns raised within your report to prevent future deaths and would respond as follows.

Matters of concern highlighted:
1. On her arrival at the Ann Marie Howes Rehabilitation Unit on 27th March 2024 Iris was assessed and found to have a Grade 4 Pressure Sore on her left heel which I was satisfied must have been present prior to her discharge the same day from the Queen Elizabeth Hospital. Mrs Carter was discharged from ward 410 on 27th October 2024 and subsequently admitted to Ann Marie Howes for ongoing rehabilitation. The ward described the patient’s skin as having a “blister is present to heel” in the morning nursing care plan before she left for transfer to Ann Marie Howes Centre. There is no documentation outlining any nurse-to-nurse handover, neither what was discussed regarding Mrs Carter’s pressure areas. We would like to apologise for this and can confirm that the presence of a pressure area was highlighted in the nurse discharge noting. The Standardised Transfer of Care Document (STOC) did include the level of pressure damage and identified the area on Mrs Carter’s skin. The team at Ann Marie Howes would have been in receipt of this document, prior to the agreement to transfer Mrs Carter into their care.

Mrs Carter’s skin was first noted to have pressure related damage on 15th October 2024 and this was documented as being a Deep Tissue Injury (DTI). A DTI is defined within the Queen Elizabeth Hospital Birmingham, in accordance with nationally recognise guidelines, as – Intact or non-intact purple/maroon area of discolouration or blood-filled blister. Pain and temperature change often precede skin colour changes. Discolouration may appear differently in darker pigmented skin. Evolution may be rapid exposing additional layers of tissue even with optimal treatment or may resolve without tissue loss. An incident form was completed on 15th October 2024, the categorisation of the level of pressure was verified by 2 nurses – 1 sister and 1 senior sister. It was described in appearance as a blood-filled blister to the heel.
2. I heard evidence during the inquest that Iris was at heightened risk of developing pressure sores given her co-morbidities and reduced mobility post her operation and that a Grade 4 pressure sore is the most serious type of pressure sore where bone is exposed and can therefore be at risk of infection. We can confirm that the Waterlow score, and other care assessments were completed within 6 hours of Mrs Carter’s admission. Mrs Carter’s risk factors were recognised, with a consistent Waterlow score during her admission of being above 25. Equipment selection: Following identification of a high Waterlow score, the mattress was incorrectly documented as soft foam, however documentation in the clinical noting, entered by a physiotherapist on multiple occasions, identified it as an air mattress – specifically documenting that the patient was struggling to mobilise from the mattress, due to the movements from the air changing cycles. Repositioning: The repositioning plan, outlining a 4 hourly regime, was consistently recommended in Mrs Carter’s care plan and was commenced from the point of admission, but we recognise this should have increased to a 2 hourly monitoring regime since the development of DTI. Following a review of the documentation, it was highlighted that there were inconsistences with the 4 hourly repositioning, and a summary of the findings are as below: Mrs Carter was not able to tolerate positional changes, and this is documented on multiple occasions. This was because of pain experienced as a result of her surgery and chronic pain experienced from a previous amputation, which in itself would have increased her risk factors. Non concordance documentation was not completed when repositioning was refused, however is clearly documented throughout the nursing noting. This lack of positional change would have further increased the risk to Mrs Carter.

There was documentation to support the use of heel off-loading devices and further documentation specifying the use of pillows. Ms Carter was reviewed daily as part of her repositioning plan, which outlined 4 hourly repositioning. The skin inspection charts were completed daily; however, the charts were not fully completed. The Waterlow assessment was reassessed weekly as per policy – this showed a consistently high Waterlow score of above 25 on every assessment.

3. However, apart from one entry on 13th October 2024 in the QEH electronic in patient noting records when it was recorded that Iris was complaining of pain on palpation of her left heel and a pillow was placed under her heel, there is no reference in the noting to it having been observed at any point that Iris had developed a pressure sore to her left heel during her admission at the QEH.
4. This leads to a concern that either the skin to her left heel was not being properly inspected or if it was that such inspections were not adequately noted in the electronic in-patient noting. Our review of the documentation outlined in the medical noting documents there was no pressure damage noted on 09.10.24 at 14:18 by the Ortho geriatrician team, who noted review of the lower limb and noted oedema present to Mrs Carter’s leg. Following the medical review on 11.10.24 no pressure damage was noted by the Trauma and Orthopaedic (T&O) doctors, but an assessment was carried out, due to Mrs Carter complaining of pain in her lower limb. On 12.10.24 T&O doctors assessed Mrs Carter’s toes, due to complaints of neuropathy and lack of movement of the toes. There was no documentation to suggest pressure damage was observed. On 13.10.24 T&O Doctors assessed Mrs Carter’s heel and palpated the heel. There was no documented evidence of pressure damage at this time. There was no record of pressure damage noted in the daily nursing care plan or repositioning regime until the 15.10.24. It was then documented that a health care assistant found a suspicious blister whilst providing personal care to Mrs Carter. This was then documented and escalated to the registered nurse caring for Mrs Carter. The blister was assessed and verified as being a Deep Tissue Injury by 2 qualified nurses (a junior sister and senior sister) and an incident report was submitted, which clearly indicated the appearance of a blood-filled blister, with the care plans then being updated to reflect this. Upon readmission to Birmingham Heartlands Hospital on 06.11.24 the pressure area was recorded as being unstageable, defined within the Queen Elizabeth Hospital Birmingham guidelines, in accordance with nationally recognise guidelines as –

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or necrosis. Until enough slough and/or necrosis are removed to expose the base of the wound, true depth cannot be determined, but it will be Category 3 or 4. Stable (dry, adherent, intact without erythema) eschar/necrosis on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed Assurance: While reviewing the incident in November 2024, the omissions in producing appropriate and accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted. In response to these findings, the senior sister and her team highlighted the omission in care to the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention strategy within the Trust. The actions taken at the time were to update the pressure ulcer prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily safety huddle on the ward. Another change in practice is that the nurse in charge of each shift will carry out a safety check, ensuring all care assessments, specifically the patient skin inspection charts, are fully completed. The senior sister has also been completing spot checks since December 2024. Tissue Viability Response:

The Tissue Viability Team (TV) receive a daily pressure ulcer report from Radar (system managing incident reports), which will inform their clinical workload for the day. Radar forms for patients who are reported as having trust acquired deep tissue injury (DTI), unstageable, category 3 or category 4 pressure ulcers are manually added to the Priority 1 section of the clinical referral excel spreadsheet. Radar is the clinical incident reporting system used at UHB. It appears that when Radar SE-18198, (the Radar form outlining the DTI to the left heel which was Trust acquired), was added to the TV clinical referral sheet it was incorrectly documented as being non-Trust acquired. Therefore, it was not placed in the Priority 1 section of the spreadsheet and Mrs Carter was not seen by TV during her QEHB admission. However, pressure ulcer prevention strategies were initiated from the point of admission. Assurance: The findings will be shared at June 2025 Tissue Viability Team meeting. Tissue Viability and the Radar team have liaised to produce a daily Radar report that more readily identifies Trust and non-Trust acquired pressure ulcers. An audit of manual transfer of data from daily Radar report to clinical referrals spreadsheet is in progress. The electronic transfer of data from the daily Radar report to the clinical referrals sheet is currently being explored.

I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously, which I hope is demonstrated in the steps that have been taken following Mrs Carter’s death.