Margaret Rodgers
19 Feb 2025 · Coroner Susan Ridge · Surrey
The coroner's concerns
1. pressure ulcer risk assessment not completed within 6 hours of admission
“The court heard that whilst the Trust has implemented a number of recommendations arising out of the patient safety review following Mrs [name redacted] death, a number have yet to be resolved in particular:”
2. insufficient nursing staff levels
“The court also heard that in December 2023 to January 2024, the period of Mrs [name redacted] admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs”
3. unresolved patient safety recommendations
“The coroner is concerned that in not completing the above recommendations arising out of the patient safety review, the Trust is placing patients at risk of early death”