Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Carol Divall · 14 May 2024 · Rachel Redman, East Sussex
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
judiciary.uk/…/carol-divall-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Carol Divall (14 May 2024) · stated 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”
judiciary.uk/…/2024-0263-Response-from-East-Sussex-Healthcare-.…
Stated action 2 · response to Carol Divall (14 May 2024) · stated 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.”
judiciary.uk/…/2024-0263-Response-from-East-Sussex-Healthcare-.…
Stated action 3 · response to Carol Divall (14 May 2024) · stated 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”
judiciary.uk/…/2024-0263-Response-from-East-Sussex-Healthcare-.…
What recurred
- 8 Jan 2026 · David Dugdale · Rachel Redman · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Carol Divall · 14 May 2024
“The RCA was insufficient and did not address all of the issues surrounding Mrs [name redacted] care”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.