Raymond Reid
PFD Report
All Responded
Ref: 2025-0135
All 1 response received
· Deadline: 6 May 2025
Coroner's Concerns (AI summary)
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.
View full coroner's concerns
(1) Mr Reid died as a consequence of sepsis caused by a combination of a urinary tract infection (UTI), pressure sores and pneumonia; it was established during the evidence that it would not be possible to determine to what extent the infection resulting from the UTI, the pressure sores and the pneumonia individually contributed to the cause of death.
(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that: a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that: a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
Responses
Action Taken
The Royal Devon Healthcare NHS Trust has an annually refreshed Trust-wide Improvement Plan, which recognizes the prevention of pressure damage as one of the top priorities. A Tissue Viability Steering Group has been developed, implemented and overseen to set out specific actions for improvement with accountability for completion. (AI summary)
The Royal Devon Healthcare NHS Trust has an annually refreshed Trust-wide Improvement Plan, which recognizes the prevention of pressure damage as one of the top priorities. A Tissue Viability Steering Group has been developed, implemented and overseen to set out specific actions for improvement with accountability for completion. (AI summary)
View full response
Dear Mr Spinney
I am writing further to the Regulation 28 Report issued on 28 November 2024 following the inquest touching the death of Mr Raymond Reid.
Mr Reid died of sepsis on a background of severe frailty. The sepsis had multiple causes but one of those was thought to be an infected pressure sore that developed while he was an inpatient in North Devon District Hospital. During the inquest, you heard evidence about the significant work that was done with the staff on Capener Ward to reduce pressure damage and that this had been successful in reducing hospital acquired pressure damage.
However, you remained concerned that further work may be needed and work around pressure damage reduction may warrant further consideration and dissemination across the Trust.
I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements.
The RDUH Trust-wide Improvement Plan
The Trust has an annually refreshed plan (the Trust-wide Improvement Plan) which is informed by scrutiny of events over the preceding year. This enables us to target our efforts on key areas of work that require ongoing quality improvement. The prevention of pressure damage has been recognised as one of these areas and continues to be one of our five main priority areas as per our Improvement plan. This issue has been on the Plan for some time, and this was refreshed in December 2024 and it remained on the plan as a top priority.
This means that we have an agreed data set of identified issues and that a regular working group reviews the improvement work that has taken place to ensure we are implementing and sustaining the improvements that we have identified. Progress is reported to a Trustwide Committee (the Patient Safety Committee) with executive oversight.
Further, pressure damage prevention has always been a key metric in the Trust’s integration performance framework. Data is reviewed by site and then aligned and reported and so parity of care and service delivery across both areas of the Trust has been scrutinised at Board level and the Quality Committee.
North Devon District Hospital Raleigh Park Barnstaple North Devon EX31 4JB
CHIEF EXECUTIVE’S OFFICE Direct Dial: Email:
Chief Executive Officer:
Chair:
Tissue Viability Steering Group
In order to deliver this priority in patient care, a Trust wide Steering Group (so covering both sites in the North and East) was established in January 2024. I am attaching the minutes from the group meeting in November 2024 which also includes the Terms of Reference for the group.
From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care.
I am also attaching the Tissue Viability Improvement Work Plan 2024-2025. This Plan is developed, implemented and overseen by the Tissue Steering Group and is updated on a quarterly basis at the meeting. It is a comprehensive work plan setting out specific actions for improvement with accountability for completion.
This Steering Group reports in to the Patient Safety Committee which includes the Directors of Nursing and Medicine as well as the Executive Chief Nursing Officer and Chief medical Officer with joint accountability for patient safety and so there is high level scrutiny of this plan and its implementation.
Delivering patient care at the front line
There is a huge amount of good work being done at a higher level to ensure that best practice is recommended in reducing pressure damage for patients.
In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work.
This will ensure that front line nursing leadership is able to implement the good practice and recommendations made by the Steering Group and to advance the Trust- wide Improvement Plan.
I hope that the above, along with the attached documents, has given you an overview of the importance in pressure damage reduction to the Trust and how this is being delivered.
Please do let me know if you have any further questions and I will be very happy to assist
I am writing further to the Regulation 28 Report issued on 28 November 2024 following the inquest touching the death of Mr Raymond Reid.
Mr Reid died of sepsis on a background of severe frailty. The sepsis had multiple causes but one of those was thought to be an infected pressure sore that developed while he was an inpatient in North Devon District Hospital. During the inquest, you heard evidence about the significant work that was done with the staff on Capener Ward to reduce pressure damage and that this had been successful in reducing hospital acquired pressure damage.
However, you remained concerned that further work may be needed and work around pressure damage reduction may warrant further consideration and dissemination across the Trust.
I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements.
The RDUH Trust-wide Improvement Plan
The Trust has an annually refreshed plan (the Trust-wide Improvement Plan) which is informed by scrutiny of events over the preceding year. This enables us to target our efforts on key areas of work that require ongoing quality improvement. The prevention of pressure damage has been recognised as one of these areas and continues to be one of our five main priority areas as per our Improvement plan. This issue has been on the Plan for some time, and this was refreshed in December 2024 and it remained on the plan as a top priority.
This means that we have an agreed data set of identified issues and that a regular working group reviews the improvement work that has taken place to ensure we are implementing and sustaining the improvements that we have identified. Progress is reported to a Trustwide Committee (the Patient Safety Committee) with executive oversight.
Further, pressure damage prevention has always been a key metric in the Trust’s integration performance framework. Data is reviewed by site and then aligned and reported and so parity of care and service delivery across both areas of the Trust has been scrutinised at Board level and the Quality Committee.
North Devon District Hospital Raleigh Park Barnstaple North Devon EX31 4JB
CHIEF EXECUTIVE’S OFFICE Direct Dial: Email:
Chief Executive Officer:
Chair:
Tissue Viability Steering Group
In order to deliver this priority in patient care, a Trust wide Steering Group (so covering both sites in the North and East) was established in January 2024. I am attaching the minutes from the group meeting in November 2024 which also includes the Terms of Reference for the group.
From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care.
I am also attaching the Tissue Viability Improvement Work Plan 2024-2025. This Plan is developed, implemented and overseen by the Tissue Steering Group and is updated on a quarterly basis at the meeting. It is a comprehensive work plan setting out specific actions for improvement with accountability for completion.
This Steering Group reports in to the Patient Safety Committee which includes the Directors of Nursing and Medicine as well as the Executive Chief Nursing Officer and Chief medical Officer with joint accountability for patient safety and so there is high level scrutiny of this plan and its implementation.
Delivering patient care at the front line
There is a huge amount of good work being done at a higher level to ensure that best practice is recommended in reducing pressure damage for patients.
In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work.
This will ensure that front line nursing leadership is able to implement the good practice and recommendations made by the Steering Group and to advance the Trust- wide Improvement Plan.
I hope that the above, along with the attached documents, has given you an overview of the importance in pressure damage reduction to the Trust and how this is being delivered.
Please do let me know if you have any further questions and I will be very happy to assist
Sent To
- Royal Devon University Healthcare Foundation Trust
Response Status
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56-Day Deadline
6 May 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 9 March 2023 an investigation was commenced into the death of Raymond Albert Alfred Reid. The investigation concluded at the end of the inquest held on 27 November 2024. The conclusion of the inquest was as follows:
Raymond Albert Alfred Reid died due to sepsis caused by recurrent urinary tract infection, pressure sores and pneumonia on a background of severe frailty.
Raymond Albert Alfred Reid died due to sepsis caused by recurrent urinary tract infection, pressure sores and pneumonia on a background of severe frailty.
Circumstances of the Death
On 6 January 2023 Raymond Albert Alfred Reid was admitted to North Devon District Hospital with a catheter related urinary tract infection. During a prolonged hospital stay Mr Reid did not respond to treatment and developed further complications of pressure sores and pneumonia. Despite treatment Mr Ried continued to deteriorate and sadly died in North Devon District Hospital on 1 March 2023.
Action Should Be Taken
I acknowledge that following the internal investigation an action plan was developed and that the learning from this matter has extended to other areas of North Devon District Hospital and parts of the Exeter site. The evidence revealed that education around pressure ulcer relief is a constant piece of work with the tissue viability team often responding when an incident has been reported. I acknowledge that there is evidence to support the conclusion that the work done so far since Mr Reid’s death has resulted in a reduction in the cases of serious pressure damage, but it is my judgement that the issues raised in this case warrant further consideration and wider dissemination across the trust and beyond to help improve outcomes for patients. (1) Consideration should be given to reviewing the process of Managing and treating pressure ulcers in hospital and where necessary to provide training and education in Trust policies and best practice to staff across the entire Trust.
Inquest Conclusion
Raymond Albert Alfred Reid died due to sepsis caused by recurrent urinary tract infection, pressure sores and pneumonia on a background of severe frailty.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.