Pauline Stirling
9 Oct 2025 · Coroner Leila Benyounes · Gateshead and South Tyneside
The coroner's concerns
1. lack of tilt documentation in positional change records
“To date, the documentation for recording positional changes only requires care staff to input the position right, left, back, in chair with no reference to positional tilt to avoid pressure damage.”
2. lack of training on wound management and pressure damage classification
“Despite safeguarding referrals made due to concerns about wound management, and the issue of wound care, incorrect classification of pressure damage, and absence of expected documentation being raised initially by tissue viability nurses in January 2024, there is no evidence before the Court of training having been undertaken, including training offered by tissue viability nurses. The only training carried out was online webinar training by a former member of staff in March 2024.”
3. inadequate documentation and record gaps
“There were candid acceptances that documentation was not completed to an accepted standard and there were gaps in the records. This is not the first inquest where acceptances were made, therefore I remain concerned that this is an ongoing issue despite evidence that this has been addressed with an auditing system.”