Source · Prevention of Future Deaths

Sheila Wexler

Ref: 2025-0028 Date: 15 Jan 2025 Coroner: Ian Potter Area: Inner North London Responses identified: 2 / 2 View PDF

A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care and prolonged immobility.

Date 15 Jan 2025

56-day deadline 12 Mar 2025 est.

Responses identified 2 of 2

Product related deaths

Coroner's concerns

AI summary

View full coroner's concerns

For context, NRS Healthcare is a nationwide supplier of medical equipment for use in people’s own homes and it has contracts with numerous NHS bodies and others, to supply and maintain such equipment. In this specific case, NRS Healthcare was required to provide and install medical equipment (at the request of one of the district nursing teams that are part of Central and North West London NHS Foundation Trust). This equipment included, a lateral turning system (known as a TOTO), an air mattress, and side rails for a profiling bed. The principal need for the equipment was for assistance in treating a sacral pressure wound.

It was confirmed in evidence, the order for the equipment from NRS Healthcare was placed correctly on 10 January 2024, on a next day delivery basis.

The MATTERS OF CONCERN is, as follows:

NRS Healthcare related matters:

I heard evidence of a delay in delivering some of the required equipment, which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer.

When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced pump with a like-for-like pump, it transpired that the replacement pump was a ’Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care.

While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli.

I heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date.

NRS Healthcare and NHS England related matters:

I heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’.

While this particular case is the first in which I have formed the opinion that delayed and defective equipment has created a risk of future deaths, I have heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, I am also of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely.

Responses

2 respondents

NHS England NHS / Health Body

15 Jan 2025 PDF

Noted

NHS England states that the contract with NRS Healthcare was managed by the London Community Equipment Consortium, to whom the Coroner may wish to refer concerns. They note that concerns about NRS Healthcare's services were escalated to the London Regional Quality Group. (AI summary)

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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Sheila Josephine Wexler who died on 17 February 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 January 2025 concerning the death of Sheila Josephine Wexler on 17 February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sheila’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sheila’s care have been listened to and reflected upon.

Your Report raised concerns over the risks posed by NHS use of NRS Healthcare for the provision of important healthcare equipment. Colleagues from NHS England’s Medical Devices and NHS Supply Chain teams and London region have reviewed your Report and aided my response to the Coroner.

NRS Healthcare are listed on the NHS Supply Chain Framework for Aids of Daily Living, for the supply of basic living aids with no service or maintenance provision included in the Framework. The Framework does not include the provision of the lateral turning system. The contract for services described in your Report has not been contracted through NHS England’s NHS Supply Chain team and our national Framework, but through the London Community Equipment Consortium, a consortium of 21 London boroughs/local authorities (LAs), in a contract awarded by the Cabinet Member for Adult Social Care, Public Health and the Voluntary Sector running from 1 April 2023 to 31 March 2028. The Coroner may therefore wish to refer your concerns to the Department of Health and Social Care (DHSC) or the London Consortium.

However, my regional London colleagues, together with the London Consortium, The Royal Borough of Kensington & Chelsea Council, and Westminster City Council have provided the below information. Background Following a successful procurement process, NRS Healthcare was awarded the equipment contract for the London Community Equipment Consortium in September 2023, supplying 21 of London’s local authorities and associated acute, community and mental health providers. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

17 March 2025

There was a short mobilisation period for the new contract due to challenges with the transition process reducing the preparatory period to three months, with a consequential impact on staffing, loss of access to depot sites and the unfortunate lack of availability of any historical service level data during the transition. This was further compounded by a cyber-attack affecting operations of NRS Healthcare and other community equipment services nationally over Easter weekend in 2024. NRS Healthcare was able to quickly establish a manual operation, but it took up to six weeks for them to recover full online systems and only in August 2024 was the backlog of cases and data gaps completed. Regional involvement Following completion of the transition to NRS Healthcare, feedback was received by the regional team from several providers. This feedback related to delays in accessing timely equipment, to support ongoing care at home in the community and to enable a timely and effective discharge. To review, address and monitor these issues, weekly oversight meetings were initiated with members of the London regional team, the commissioners of the equipment contract (Royal Borough of Kensington and Chelsea/Westminister City Council) and key partners, to identify areas of concern, review core key performance indicators and monitor improvement trajectories. Current position Performance has improved to expected contractual levels following a significant recovery/improvement process, but timings were set back due to the cyber-attack. Consortium-wide:
• 88% “delivery in time” performance across the board.
• 95% on “same day delivery” from Greenford depot, with >85% from Tottenham and Sidcup.
• “Next day” activities performing at 93% across consortium.
• Key issues relating to stock management and visibility are largely resolved.
• Work to further refine the catalogue with clinical leads (occupational therapists) is in progress to: a) ensure that all locally defined ‘special items’ are listed with ‘close technical equivalents’ clearly linked, and b) reduce the number of products in key, high volume, order lines to enable NRS to manage the supply chain more effectively The statistics quoted above are from the period of November 2024 but remain broadly consistent and refer to all deliveries across the catalogue for 21 Boroughs. Commissioners are provided with a monthly picture of these performance metrics. NRS Healthcare actions

• NRS Healthcare have mobilised significant additional senior management and executive presence to oversee and ensure that the London Community Equipment Consortium contract is performing and meeting the needs of prescribers, patients, and their families.
• Following earlier challenges with performance, NRS Healthcare implemented a refreshed complaints and escalation process for prescribers and local contract leads.
• During 2023/4, permission was granted for NRS Healthcare to use its Business Continuity Plan to invest in additional cleaning and recycling capacity at a site named London North. This assisted with reducing the backlog and increasing stock availability.
• Specific interventions have taken place at key sites and Boroughs experiencing challenges were identified.
• This has been successful in identifying and addressing issues as early as possible.
• NRS Healthcare has appointed dedicated ‘Community Engagement Officers’ to build relationships with prescribers and provide support on-site where issues arise. These roles have been particularly helpful working with teams in Discharge Hubs at hospital sites and Community Health Trusts.
• Training days for prescribers have been made available by NRS Healthcare where specific needs have been identified.
• NRS Healthcare have been highly responsive when made aware of issues and see them through to resolution. Ongoing governance The London Community Equipment Consortium has robust governance in place to oversee the contract. This includes:
• Directors’ Board for key strategic decisions, meeting quarterly.
• Consortium for collective oversight of contract management, finances, and the NRS improvement plan, which meets monthly.
• Contract Management Board for local contract leads to hear responses and updates from NRS Healthcare, coordinated through the consortium team. This meets monthly.
• Regular Equipment Review Groups managed by a Clinical Lead with Occupational Therapy representatives from across the consortium to manage the catalogue. This meets at least monthly.
• A series of workstreams established to address any live areas for development, including invoicing, IT, data validation, and stock controls.
• Access to community equipment is identified on the regional risk register and remains under monthly review.
• Fortnightly oversight meetings with ICB discharge leads and social care are in place to identify any specific pathway delays, which includes any related community equipment supply challenges.
• NHS England’s London regional team continue to meet with the equipment commissioners and key partners to oversee and monitor key performance indicators, to support consortium members and associated providers.

North Central London Integrated Care Board North Central London Integrated Care Board (NCL ICB), who plan the health services in the area where Sheila was from, have also been undertaking significant work with the London Consortium and NRS Healthcare over the past year. NCL ICB advise that there were issues with the transfer of services from the previous provider to NRS Healthcare. The cyber-attack in 2024 suffered by NRS Healthcare (referenced above) further exacerbated issues with their responsiveness to concerns, and issues with NRS Healthcare were escalated by providers in a timely way to the ICB last year. Throughout 2023, NCL ICB had received several concerns, patient safety incidents and complaints relating to the delivery and collection of equipment. However, the number of complaints has now reduced significantly in a relatively short space of time. The concerns were escalated to the London Regional Quality Group (part of formal NHS governance processes), where they have been escalated to the national team at NHS England and have been discussed at the regional Chief Nurses’ meeting. Although improvements have been made, some issues continue to be reported by clinical teams in relation to the timeliness of delivery of equipment. Across NCL, these issues are managed through the four Local Authorities across Barnet, Camden, Haringey and Islington. NCL ICB have supported their healthcare providers in negotiations with NRS Healthcare, as well as LA colleagues, to resolve the issues, recognising that oversight and management of the contract and accountability is the responsibility of the London Community Equipment Consortium. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Sheila, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

NRS Healthcare

11 Mar 2025 PDF

Action Taken

NRS Healthcare is providing additional training to customer service operatives, enhancing working arrangements, reorganizing Community Equipment Technician teams, and improving communication processes. The London Community Equipment Consortium completed an equipment review of lateral turning systems, and the TOTO should be phased out. (AI summary)

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Dear Mr Ian Potter,

INQUEST INTO THE DEATH OF SHEILA JOSEPHINE WEXLER (DATE OF DEATH 17 FEBRUARY 2024) RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This is the response of Nottingham Rehab Limited (trading as NRS Healthcare) (“NRS”) to a Report to Prevent Future Deaths (“PFD Report”) dated 15 January 2025 which was issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The PFD Report was issued subsequent to an Inquest into the death of Mrs Sheila Josephine Wexler on 17 February 2024 which the PFD Report states concluded on 14 January 2025.

NRS offer their sincerest condolences to the family and loved ones of Mrs Sheila Josephine Wexler.

NRS has set out below the context in which this response is provided.

NRS was not aware of the Inquest until it received the PFD Report on 16 January 2025. NRS had not previously been asked to provide a witness statement, or evidence of any kind to the Inquest. It was not provided with any notification of the Inquest or documentation relating to the matters referenced in the PDF advance of its conclusion.

On receiving the PFD Report and in order to understand the source of the issues it sets out and properly respond, NRS promptly wrote to the Assistant Coroner to request the transcript of Inquest and disclosure of documents. The Inquest bundle was subsequently disclosed to NRS, however the Coroner declined to provide the transcript of Inquest. NRS has therefore not had access to the evidence heard by the Coroner during the Inquest. NRS has previously assisted Coroners in other Inquests and would have been happy to do so in relation to the death of Mrs Wexler. It would have welcomed the opportunity to provide relevant information to the Assistant Coroner to enable the Inquest to have all of the information about its involvement beyond that which appears to have been provided by unconnected third parties who had been designated as Interested Persons for the purpose of the Inquest.

NRS notes that, before the conclusion of the Inquest and notwithstanding the matters identified by the Assistant Coroner in the PFD it had not been invited to participate as an Interested Person by virtue of either s.47(2)(f) or
s.47(2)(m) of the Coroners and Justice Act 2009.

NRS regrets not having been provided with that opportunity and the consequence is that a PFD has been issued containing matters that NRS may have been able to clarify and means, of course, that it is not privy to the evidence heard at the Inquest and that is explicitly referenced in the PFD Report relating to NRS operations.

An example of the difficulty created in responding to the PFD when NRS has not had the opportunity to hear the evidence at the inquest is that the PFD contains a reference to the Coroner being told “that the service provided was still ‘not great’”. It is clear that this statement during the hearing was a consideration for the Assistant Coroner in issuing the PFD. Similarly the PFD references the Coroner hearing evidence of “numerous and ongoing delays

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 and ‘problems’ in the service provided by NRS Healthcare”. However, on the face of the PFD these concerns appear anecdotal and it is respectfully submitted that they are too vague for NRS to be able to properly respond to without having heard the context in which these comments were made.

In view of the context set out above, this response therefore is made to the best of NRS’ ability in seeking to address the concerns raised in the PFD Report insofar as they relate to NRS operations.

It may be relevant to note that NRS was victim of a significant cyber-attack in April 2024 which hinders access to some, but not all, previous records.

Response to concerns regarding the provision of equipment to Mrs Wexler

It is important to note at the outset that NRS is a specialist provider of community equipment to people across the UK on behalf of the NHS and Social Care. NRS install, deliver, maintain and recycle such equipment. The equipment itself is prescribed by healthcare professionals and others authorised to do so who work in the NHS and for Local Authorities. NRS does not have any role in assessing people’s needs. NRS operates an electronic catalogue of all care items that Commissioners and Contract Leads for London have requested that NRS Healthcare hold. This equipment can only be ordered by NHS or Social Care prescribers. No other equipment is available to NRS or its Community Equipment Technicians.

To address the concerns of the Coroner, NRS has set out below key aspects in the chronology of the provision of equipment to Mrs Wexler, which is derived from available NRS records and statements provided to the Inquest by others and provided in the disclosure bundle.

The products relevant to the PFD which were ordered from NRS and provided to Mrs Wexler by NRS during the relevant time period were a TOTO lateral turning system and a Dynamic Mattress. NRS notes that the manufacturer’s information regarding both of these items of equipment references that they are prescribed to treat and prevent pressure ulcers. They are not prescribed to prevent a pulmonary embolism.

NRS has not been provided with any medical evidence linking the provision of equipment for pressure ulcers with the development of a pulmonary embolism and is therefore unable to comment on this concern in the PFD.

The PFD report suggests an initial delay in the delivery of equipment. This is not accepted by NRS. Its records show a next day order was received on 10 January 2024 at 17.17. The order was for a Dynamic Mattress, a TOTO turning system (“TOTO”) and side bumpers. The cut off for next day orders is 17:00 and therefore the ‘next day’ for an order placed at 17:17 on 10 January is 12 January. The delivery of the Dynamic Mattress and TOTO was made on 12 January. The bumpers could not be installed as side rails had not been ordered by the prescriber for the bed. The order for bumpers was cancelled. On 12 January a same day order was received from the prescriber for side rails and these were delivered that day. The position therefore on 12 January was that a brand new (not refurbished) Dynamic Mattress, TOTO and side rails were in place and had been delivered by NRS within the service agreement timescale.

The statement of , Tissue Viability Specialist Nurse confirms that on 18 January Mrs Wexler was in the hospital bed with the TOTO on. No concerns were noted on this date.

NRS records show that a visit was made by one of its out of hours Community Equipment Technicians on 21 January who was at the property for 15 minutes. The available notes on the NRS system do not state what action was taken on that visit and this does not seem to be addressed in the Inquest bundle statements.

On 22 January NRS records show that a call was received by NRS to state that either the Dynamic Mattress or the TOTO were not working. An NRS Community Equipment Technician visited that day, swapped both the Dynamic Mattress and the TOTO and tested both before leaving the premises. NRS records show that the Dynamic Mattress and TOTO were both tested by NRS after collection, as is standard practice to establish what repairs are required before reuse. Neither piece of equipment was found to have a fault.

From 23 January to 29 January (inclusive) no calls are recorded by NRS as having been received by them regarding malfunctioning equipment. It is clear from the statement of that the district nursing team undertook regular visits and this included 23 and 27 January. NRS is confident that a fault in the equipment would

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 have been obvious to the District Nurse and they would have reported this to NRS. No such concern was raised and the statements of (District Nurse Team Leader) and (Tissue Viability Nurse) also do not state a concern was raised to NRS at this time by any medical staff or by the family. There is a slight discrepancy between the Inquest statement of , which states that Mrs Wexler’s daughter said NRS attended on 23 January and NRS notes, which record that the Community Equipment Technician attended on 22 January. NRS cannot explain this discrepancy. Regardless, no other report of a concern was made to NRS until 30 January.

On 30 January at 14:08 NRS records show a request was made for a same-day repair of the TOTO due to the user being unable to adjust the settings or timings. This was reported by the District Nurse Team Lead, . The Community Equipment Technician attended at 16:06 and notes are that there was no answer at the property. On 31 January NRS phoned the daughter at 12:45 and there was no response. On 1 February contact was made and a visit arranged for 2 February. On attending the property the NRS Community Equipment Technician noted that Mrs Wexler was asleep and they were unable to inspect the equipment. The daughter requested that the Community Equipment Technician returned the following morning. The Community Equipment Technician returned the following morning on 3 February. They noted that a further visit was required for the repair to the TOTO to be undertaken and this visit was made on 5 February with the repair being noted as made.

A Dynamic Mattress in working order was at the property for the complete time period. The Dynamic Mattress itself has its own pump which is separate from the TOTO and for this reason the Dynamic Mattress would have provided pressure relieving qualities while in use. The TOTO is a turning system is installed underneath the mattress to provide a turning platform which provides additional pressure relief for those unable to adjust their own position in bed.

In summary the timeline established from NRS records is:

From 12 January- 29 January (inclusive), the Dynamic Mattress and TOTO were at the property and in working order, having been installed by an NRS Community Equipment Technician on 12 January. The possible exception to this is 21-22 January when replacement equipment was ordered and provided. However, the equipment removed from the property at this time was found to be in working order on inspection.

Between 30 January -5 February several visit attempts were made which related to the TOTO only, with this being repaired on 5 February.

Tri-Pos Bariatric Alternating Air Cushion Pump

The PFD report states that “An engineer attended Mrs Wexler’s home, on behalf of NRS Healthcare, to repair the equipment but used a pump that was not compatible with the turning system.” The statement from

suggests the incompatible equipment was a Tri-Pos Bariatric Alternating Air Cushion Pump.

This pump is not one which is supplied by NRS. It is not available on the equipment catalogue and therefore not possible for it to either be ordered by a prescriber or supplied to a service user by a Community Equipment Technician. An online search shows that this pump is publicly available as a rental product.

The Community Equipment Technician attending Mrs Wexler’s address is very experienced and has completed training on the TOTO. NRS has taken very seriously the allegation that the NRS Community Equipment Technician replaced the TOTO pump with one not available through NRS and has spoken to the Community Equipment Technician concerned. The Community Equipment Technician has confirmed that he recalls attending the property and replacing the TOTO pump with another TOTO pump. He confirms that he did not see another pump and had no method of accessing equipment other than that on the NRS catalogue.

NRS is unable to retrieve the email sent by with photos of the Tri-Pos Bariatric Alternating Air Cushion Pump and we note it does not appear in the Inquest disclosure. NRS acknowledge they may not be able to retrieve this due to the cyber-incident.

Sherwood House | Cartwright Way | Forest Business Park | Bardon Hill | Coalville | Leicestershire | LE67 1UB NRS Healthcare is the trading name of Nottingham Rehab Limited. Registered in England & Wales No. 1948041 NRS therefore does not accept that it was responsible for the installation of the Tri-Pos Bariatric Alternating Air Cushion Pump.

In summary:

• NRS is not a prescriber of equipment. Equipment can only be supplied by NRS if it is ordered from NRS by a prescriber.
• NRS only supplies equipment in an approved catalogue.
• NRS Community Equipment Technicians only have access to equipment in the catalogue.
• The Tri-Pos Bariatric Alternating Air Cushion Pump has never been available in the NRS catalogue.
• It is therefore impossible for the Tri-Pos Bariatric Alternating Air Cushion Pump to have been ordered from NRS by a prescriber or supplied by an NRS Community Equipment Technician.

Service Improvements

NRS took over the contract to supply 21 London Boroughs with healthcare equipment in April 2023. Since taking over the contract NRS has taken significant steps to evolve and improve the quality of customer services and equipment provided to service users.

This includes;

• Providing additional training to all customer service operatives;
• Enhancing the working arrangements between customer service operatives and the management team in service centres;
• Reorganisation of Community Equipment Technician teams so they are focused on individual London Boroughs;
• Instigation of a daily debrief and feedback on any unsuccessful activity;
• Improved communication from Community Equipment Technician to managers when they have been unable to make contact with a service user at the premises;
• An improved communications process with hospital discharge teams;
• A new performance monitoring system; and
• Improvements to the product ordering system to make it clearer which equipment is in place.

Additionally, on 07 August 2024, The London Community Equipment Consortium completed an equipment review of lateral turning systems to evaluate what is currently available on the standard catalogue. During the review seventeen clinicians reviewed five lateral turning systems from three suppliers/manufacturers. A full market scope was conducted to compile a list of all relevant suppliers and products. A shortlist of products was compiled to review in person, based on an expert Tissue Viability Nurse undertaking a desktop review. The result of the review is that the TOTO should be phased out over time and not reissued to service users, gradually replacing these with a turning system which performed better in the review.

NRS hope that this information has provided clarity to the Coroner subsequent to issuing the PFD Report. NRS also hopes that notwithstanding the fact that NRS does not accept the concerns in the PFD report, for the reasons described, actions have been undertaken and continue to be undertaken by NRS to improve its service.

Report sections

Investigation and inquest

On 29 February 2024, I commenced an investigation into the death of Sheila Josephine WEXLER, aged 87 years at the time of her death.

The investigation concluded at the end of an inquest on 14 January 2025.

The conclusion of the inquest was a short narrative conclusion in the following terms: ‘natural causes, contributed to by increased immobility as a result of delayed and defective turning equipment being supplied for the treatment of a pressure ulcer.’

The medical cause of death was: 1a bilateral pulmonary embolism II dementia, ischaemic cerebral stroke, pneumonia, frailty, grade 4 sacral pressure ulcer

Circumstances of the death

Mrs Sheila Wexler lived with dementia and other significant comorbidities for a number of years. In the months prior to her death, she was thought to be entering the final phase of her life and a package of maximal home treatment was in place as a ceiling of care.

In January 2024, Mrs Wexler developed an unstageable sacral pressure ulcer. The district nursing team ordered equipment from an external supplier (NRS Healthcare) which, among other things, would turn Mrs Wexler regularly to assist in the treatment of the pressure ulcer. There were delays in some of the equipment arriving and the turning equipment was not properly functioning. An engineer attended Mrs Wexler’s home, on behalf of NRS Healthcare, to repair the equipment, but used a pump that was not compatible with the turning system. As a result of these issues with the equipment, Mrs Wexler’s immobility was significantly increased for a period of days, which added to her underlying risks of developing a pulmonary embolism.

Mrs Wexler died at home on 17 February 2024. The immediate cause of her death was bilateral pulmonary embolism. A number of her comorbidities contributed to this. The increased immobility as a result of delayed and defective equipment being supplied also more than minimally contributed to her death.

Copies sent to

Central and North West London NHS TrustNHS North East London Integrated Care BoardNorth Central London Integrated Care Board

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0028
Date of report: 15 January 2025
Coroner: Ian Potter
Coroner area: Inner North London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Mar 2025 (estimated).

Sent to

NHS England

NRS Healthcare

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.