PFD report

Jane Bullock Wilson Stables · Prevention of Future Deaths report

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Issued 15 Dec 2016•South Yorkshire (Eastern)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns: 1
Recipients: 1
Responses found: 2
Stated actions: 12

Recipients and published responses

Rotherham Doncaster and South Humber NHS Foundation TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 13/04/2016 I commenced an investigation into the death of Jane Bullock Wilson Stables, 70. The investigation concluded at the end of the inquest on 15 December 2016. The conclusion of the inquest was a Narrative conclusion. The cause of death was: 1a. Sepsis 1b. Pressure Ulceration of skin, 1c. Immobility from Rheumatoid Arthritis, 2. Ischaemic heart disease, frailty, malnourishment.

Circumstances of the death

Mrs Stables had a long history of severe rheumatoid arthritis treatment for which was limited due to her morbid fear of hospitals to the extent that she declined to attend for consultations. The disease progressed and by the end of 2015 she was in considerable pain with contractures and had become bed bound. District nurses were visiting regularly, their visits were increased. She also had carers attending four times a day. The evidence I heard from the district nurses, tissue viability nurse and the carers was entirely consistent with regard to the extent of Mrs Stables pain and challenges this presented in providing her with care and repositioning her as required. The pain was never properly controlled and thus she was caused severe pain when care was delivered. In spite of this there was a failure on the part of the nurses and carers to effectively communicate those concerns with the General Practitioner which would have enabled further pain relief reviews to have taken place and thus the possibility of enhanced pain relief which would have more effectively managed that pain. In addition, the district nurses put in place a care plan for regular turning and that she was to be repositioned on each of the four attendances that the carers made each day. Despite this, the turns were not carried out as directed, the documentation regarding turns and repositioning is lacking and on some days there appeared to be no repositioning at all. From the 14th March to the 21st March the notes are particularly scant with regard to repositioning and turns and by the 21st March the community staff nurse was so concerned that the advice to regular turn had not been followed that she raised this again with ████████ left a note for the carers and also left repositioning charts. From that point on there was increased frequency in turns and recording of the same but the back area on the coccyx noted on the 16th March together with other pressure sores had significantly deteriorated and my conclusion is that a contributory factor was the failure to adhere to the care plan and in particular the turns required under that plan. On the 30th March Mrs stables was admitted to the Doncaster Royal Infirmary as an emergency and she passed away there on the 2nd April 2016.

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

Ineffective communication about significant pain levels between nurses and the general practitioner
Part of recurring concern: Unreliable communication of patient-care information between clinical staff

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response 3

Action
Consider direct professional dialogue about pain management when treatment is not optimised, regardless of patient or carer communication channels.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated planned
Action
Convene a multidisciplinary meeting and produce a documented summary of learning and actions.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated completed
Action
Operate a Lead Nurse referral system for branches to obtain clinical advice, contact GPs when necessary, and review patient documentation and care plans.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed

Respondent positions 1

Position
When District Nurses were attending, they were responsible for escalating concerns to the GP, so carers were not required to contact the GP directly.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareRedirects responsibility

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 9

1
Disseminate Regulation 28 learning through senior nurse and subsequent cluster meetings, with meeting minutes forwarded as evidence.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated planned
2
Deliver rolling pain-management training for patients with dementia or cognitive impairment and incorporate Regulation 28 learning into future training slides.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progress
3
Conduct recurring field assessments of carers’ records and documentation, at least every six months or more frequently when concerns arise.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed
4
Review practices, policies, and procedures governing when and how carers use slide sheets, and provide the review outcome to the coroner.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated planned
5
Provide care coaches or buddies to mentor less experienced carers on care-plan compliance, record-keeping, and care standards, with continuing supervisory support.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed
6
Review all training documents on a two-year cycle or sooner when guidance changes.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated in progress
7
Require qualified clinician oversight and approval of clinical training materials.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed
8
Automatically refer CIAMS reports of marks on patients’ bodies to customer services for necessary referrals, including safeguarding referrals for pressure sores, before closure.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed
9
Use amended care plans with visual summaries and condition-based prompts that mandate referral to the local branch or Lead Nurse when indicated.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareStated completed

Recipient positions 1

1
Pressure sores predated care, and carers regularly repositioned the patient under the care plan, disputing that staff failed to follow it.
Stated by Nestor Primcare Services Limited t/a Allied HealthcareDisputes the concern

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised1

Ineffective communication about significant pain levels between nurses and the general practitioner

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 1

Recipient-stated actions 9

Recipient positions 1