Kore Elizabeth Padgett · Prevention of Future Deaths report

On 13 November 2024 I commenced an investigation into the death of Kore Elizabeth PADGETT aged 90. The investigation concluded at the end of the inquest on 13 August 2025.

The conclusion of the Inquest was that Kore Elizabeth Padgett died as a consequence of naturally occurring disease contributed to by injuries sustained from an accidental fall requiring immobilisation in a hard collar. Kore struggled to tolerate the placement of the collar with it impacting upon her overall health and ability to swallow, placing her at high risk of aspiration and requiring the assistance of a nasogastric tube for feeding.

In the early hours of the 8th September 2024, Kore Elizabeth Padgett was admitted to Huddersfield Royal Infirmary following an accidental fall down the stairs at home. In the course of her admission, Kore experienced pain in her neck and was subsequently diagnosed with an unstable fracture to her neck, requiring immobilisation in a hard collar. Kore had previously undergone extensive surgery on her neck and given her age and associated frailty, she struggled to tolerate the placement of the collar, which impacted upon her ability to swallow requiring the aid of a nasogastric tube for feeding purposes. The pressure applied by the collar caused Kore to develop three separate pressure sores and she experienced further difficulties as the collar was noted to move whilst in situ, with the staff on the ward being unable to appropriately adjust the collar as they had not be trained to do so.
Kore’s care was managed in part through the tissue viability nurses who experienced difficulties in providing pressure relief as a consequence of the ongoing requirement for Kore to wear the collar. On the 2nd October 2024, advice was sought from the neurosurgical team in Leeds as to the ongoing need for the collar and on the basis of the information provided at the time, advice was given to continue with the use of the collar until Kore could be assessed by the neurosurgical team. A request was made for Kore to be assessed within a week but this was not arranged.
Kore’s health continued to deteriorate and she went on to develop aspiration pneumonia, requiring chest physiotherapy which was limited by the placement of the collar. No further contact was made with the neurosurgical team to discuss the ongoing effects of the collar on Kore’s physical health and therefore Kore was unable to make an informed decision as to whether or not she wanted to continue wearing the collar or could remove it and accept any associated risks.

Kore went on to develop recurrent aspiration pneumonia and on the 23rd October 2024, despite having previous periods of improvement, her condition rapidly deteriorated and she passed away.

i)        The absence of training for staff on the ward in respect of the correct fitting of a hard collar;
ii)       The absence of communication by the treating clinicians with the neurosurgical team at Leeds in respect of treatment options for Kore given the significant impact that the wearing of the collar was having on Kore with the development of pressure sores, difficulties with her swallow and increasing risks of aspiration.
iii)      The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed.
iv)      The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.