Inadequate pressure sore management and monitoring
East Sussex Healthcare NHS Trust received 2 coroners' reports about this hazard between 14 May 2024 and 8 Jan 2026.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
Original on judiciary.uk ↗ East Sussex Healthcare NHS Trust responded, stating 3 specific actions.Response (PDF) ↗
“case. We recognise that the mouthcare received by Mrs [name redacted] was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording. High risk patients now receive daily mouthcare reviews, medium risk patients”
Stated timescale: 2022
“We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur. We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.”
Stated timescale: mid-May
1 more stated action in the Promises tab.
- 1 year 8 months laterClosely relatedConfidence 0.85 · high
“Poor management of [the deceased]'s pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol.”
Original on judiciary.uk ↗ East Sussex Healthcare NHS Trust responded.Response (PDF) ↗
- All reports to East Sussex Healthcare NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2026David Dugdale1 year 8 months after Carol Divall · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the identification and management of pressure sores in patients under the trust's care. The earlier report notes inadequate root‑cause analysis and documentation, while the later report describes worsening of a sore due to poor pain relief and monitoring.
Carol Divall · 14 May 2024
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
Original on judiciary.uk ↗ David Dugdale · 8 Jan 2026
“Poor management of [the deceased]'s pain. In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst an in patient at EDGH, he was only receiving oral paracetamol.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We acknowledge the unacceptable delay in dealing with the pressure sore. We note that category 2 pressure damage was first documented in Mrs [name redacted] health records on 20 September 2022, ten days before the referral to the TVN. In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential”
Stated action · timescale: 2022
“case. We recognise that the mouthcare received by Mrs [name redacted] was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording. High risk patients now receive daily mouthcare reviews, medium risk patients”
Stated action · timescale: mid-May
“We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur. We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.”
Stated action · timescale: 20 September 2022
“We acknowledge the unacceptable delay in dealing with the pressure sore. We note that category 2 pressure damage was first documented in Mrs [name redacted] health records on 20 September 2022, ten days before the referral to the TVN. In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to East Sussex Healthcare NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2026 | 0.63 | 0.01 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.