Susan Margaret Barrett · Prevention of Future Deaths report

On 2nd August 2024 I commenced an investigation into the death of Susan Margaret Barrett, aged 81 years’. The investigation concluded at the end of the inquest on the 18th September 2025.

The conclusion of the inquest was a Narrative Conclusion focussed on those aspects of the inadequate care, management and treatment that probably more than minimally contributed to the avoidable deterioration of an ultimately fatal sacral pressure ulcer.

Susan Margaret Barrett died on 30th July 2024 on Trinity Ward, Fryatt Hospital, 419 Main Road, Essex from Sepsis arising from Osteomyelitis caused by a Grade 4 sacral pressure ulcer on a background of Dementia.

The identified and significantly sub-optimal care leading to the deterioration of the sacral pressure ulcer to Grade 3 initially arose during Mrs Barrett’s eight-day period as an in-patient in Colchester General Hospital. The deterioration continued following her return home under the care of the Community Nursing Team and the Tissue Viability Service, with the ulcer progressing to Grade 4 and the subsequent confirmation of infection to the bone resulting in the sepsis from which she died. Significant deficits in the communication between the Community Nursing Team and Tissue Viability Service led to at least a two-month delay in Mrs Barrett receiving the daily nursing care that, it was agreed by the witnesses, she should have received shortly after her discharge from Hospital and would likely have made a significant difference to the rate and nature of the deterioration of the pressure ulcer. Evidence was received, and accepted by the Court, that these aspects of causative failures in care have been addressed.

The evidence disclosed that Mrs Barrett received optimal care following her transfer from Colchester General Hospital acute care to Trinity Ward in the Fryatt Community Hospital.

However, serious concerns were raised in evidence by East Suffolk and North Essex NHS Foundation Trust (ESNEFT) witnesses relating to the impact and consequences of an absence of embedded, dedicated Tissue Viability Nurses (TVNs) and a Tissue Viability Service (TVS) across the two ESNEFT Community Hospital Sites which, together, involve three Wards (including Trinity Ward) with, cumulatively, some 77 patient beds.

The Community Hospital Wards are Nurse Practitioner led and based on a GP model but since 2023 have seen the withdrawal of embedded TVNs or a TVS across all Wards. The evidence from both the Colchester General Hospital Matron and the Community Tissue Viability Lead Nurse confirmed that whilst this has been formally recognised as a ‘risk’ - and attempts at mitigation have been attempted - the steps taken have been inadequate.

In her evidence the Tissue Viability Lead Nurse confirmed that she had raised and escalated her concerns regarding the change in policy and informed the Court that she had felt it necessary to “block” some transfers of vulnerable patients from the Acute Hospital to the Community Hospital, expressly on the basis that the absence of an embedded TVS gave rise to a serious risk of the deterioration of these frail and vulnerable patients’ pressure ulcers to the extent, she confirmed, that such transfers presented a risk of future deaths. Notwithstanding the ‘blocking’ she has been required to resort to, she made reference to an increase in pressure damage in the Community Hospital Wards in a 2025 three month period compared to the same period in 2024.