Jean Waldron

Good Morning, Regulation 28 Response – Prevention of Future Deaths Organisation: Ignite Health and Homecare Deceased: Mrs Waldron Regulation 28 Report dated: 08/01/2026 This response is provided pursuant to paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and addresses the matters of concern raised by the Coroner. Matters of Concern The Coroner expressed concern that:  a carer, who was a Team Leader, undertook wound-related activity despite clear instruction not to do so; and  this may indicate a lack of understanding by carers regarding the limits of their role and the need to follow specialist clinical advice. Agency Response The agency has carefully considered the evidence heard at the inquest and the Coroner’s concerns. The evidence confirms that on 15 January 2025, the District Nurse Clinical Lead issued a clear written instruction stating that carers were not authorised to provide any care in relation to Mrs Waldron’s pressure sore, as wound care fell outside the scope of practice and licensing of the agency’s staƯ. The Team Leader who gave evidence confirmed that she had read and understood this instruction. This demonstrates that the agency’s communication, governance, and escalation systems were eƯective and that staƯ were aware of the limits of care they were permitted to provide. The actions taken on three occasions thereafter were undertaken in direct contravention of that instruction, outside agency policy and training, and were not directed, authorised, or endorsed by the organisation. These actions were based on the individual’s personal judgement rather than any deficiency in the agency’s systems, training, or governance. The evidence from the Lead Tissue Viability Nurse further confirms that the actions taken were clinically inappropriate, reinforcing the necessity of carers adhering strictly to scope-of-practice boundaries — a requirement already embedded within the agency’s policies and training framework. Action Taken / Action to be Taken

Without admission of fault, and in order to further reduce the risk of recurrence, the agency has taken and/or will take the following steps:
1. Scope-of-Practice Reinforcement All staƯ have received reinforced guidance clarifying that wound care and pressure sore management are outside the scope of carer practice and must only be undertaken by appropriately qualified persons.
2. Escalation and Accountability Reminder Formal reminders have been issued confirming that where clinical concerns arise, staƯ must escalate to district nursing or medical professionals and must not act independently outside authorised duties.
3. Governance Oversight Existing supervision and audit processes have been reviewed to ensure continued oversight of adherence to scope-of-practice boundaries. The agency is satisfied that these actions appropriately address the Coroner’s concerns and further strengthen safeguards already in place. Kind Regards, Operations Director Integrity, Accountability, Vision, Compassion, Purpose, Solution-Focus