Geoffrey Gudgeon

Dear Mr Cox, Re: The Late Mr Geoffrey Gudgeon - Regulation 28 PFD Report and Response I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 16 February 2026 and received on the 17 February 2026 This was issued following the inquest into the death of Mr Geoffrey Gudgeon which was heard on 16 February 2026. I would like to take this opportunity to express my sincerest condolences to the family of Mr Gudgeon for their loss. During the inquest, the evidence revealed matters giving rise to concern. Which is as follows:
1. There is a capacity issue in Cornwall concerning timely admission and treatment of stroke patients. Please find below the response from the Trust and details of the actions taken in relation to the above concern. Response: The Trust has undertaken significant work on improving stroke care at RCHT through our Stroke Improvement Board which meets monthly. A combination of more robustly ringfencing stroke beds (Stroke Bed Escalation Plan), earlier specialist reviews (increased Stroke Consultant availability in ED and Phoenix Ward), and rapid reviews of in-house data has led to a significant improvement in getting stroke patients to Phoenix Ward within 4 hours and staying there for >90% of their inpatient stay (both nationally mandated targets). In financial year 2024/2025, only 38% of Outstanding Care for One + All □□ disability □3 confident
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stroke patients were admitted to Phoenix Ward within 4 hours. This improved in the available 2025/2026 data, with 52% patients achieving the 4-hour target, and was accompanied by a sustained reduction in stroke mortality. I attach a copy of the Stroke Metrics to support this and if it would be of assistance, I can share with you the Stroke Action Plan for information. All the above are reported through the Trust Quality Assurance Committee on a monthly basis. From December 2025 to date, we have however seen a down-turn in our 4-hour stroke unit target. This is impacted by the number of beds across the entire stroke pathway, including Stroke Rehabilitation Unit beds when a patient no longer requires an acute stroke bed at RCHT. The current bed base was calculated on models that are now several years old and does not take into account the significant increase in stroke numbers seen. CIOS ICB has undertaken to review this provision. Patient flow is also linked to staffing, particularly within the therapy teams, which are not currently staffed to national guidelines. The ICB has also undertake to review this provision. The RCHT Stroke Improvement Board have called for urgent capacity/ demand work and bed modelling. As described, responsibility for this action lies with the ICB. A multi-stakeholder discussion regarding the development of a unified, system-wide Integrated Stroke Pathway Capacity and Demand Model across Royal Cornwall Hospitals NHS Trust (RCHT), Cornwall Foundation Trust (CFT), and NHS Cornwall & Isles of Scilly ICB took place on 4th March 2026. The aim is to establish a consistent, efficient, and clinically robust stroke pathway supported by accurate modelling, sustainable workforce planning, and strengthened governance. This meeting led to an agreement that a cross-organisational working group be formed to deliver a business case including up to date capacity and demand modelling outputs, and a robust workforce plan with new models of care, with a timeframe of 3 months. I hope that this letter provides both you and Mr Gudgeon’s family with assurance that the Trust has taken seriously the concerns raised in your report and that the Trust has taken the appropriate action to prevent future deaths.