The Department of Health and Social Care has referred the concerns regarding guidance and training for doctors on pressure sore management in care homes to NHS England, stating it is more appropriately addressed by them. (AI summary)
Source · Prevention of Future Deaths
Albert Bellingham
Ref: 2026-0176
Date: 12 Mar 2026
Coroner: Andrew Walker
Area: North London
Responses identified: 1 / 2
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There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing with pressure sores.
Date
12 Mar 2026
56-day deadline
24 Jun 2026 est.
Responses identified
1 of 2
Coroner's concerns
There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing with pressure sores.
View full coroner's concerns
Consideration of guidance to support interventionalist, supervisory role with appropriate training for doctors working in care homes when dealing with pressure sore.
Responses
Department of Health and Social Care
Central Government
Noted
Dear Andrew Walker Thank you for the Regulation 28 report of 12 March 2026 sent to the Department of Health and Social Care about the death of Albert Thomas Bellingham. I am replying as the Minister with responsibility for NHS workforce. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Bellingham’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns about the care of pressure sores in care homes and in particular, the consideration of guidance and appropriate training for doctors working in care homes when managing pressure sores. In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised. I hope this response is helpful.
Report sections
Investigation and inquest
On the 12th November 2024 I commenced an investigation into the death of, Albert Thomas Bellingham aged 84. The investigation concluded at the end of the inquest on 25th February 2026 . The conclusion of the inquest was a consequence of inadequate preventative treatment, amounting to neglect, of a sacral sore.
The medical cause of death was 1a Entercloster boltae bacteraemia, 1b sacral sore, 11 Odontoid peg fracture following fall in September
The medical cause of death was 1a Entercloster boltae bacteraemia, 1b sacral sore, 11 Odontoid peg fracture following fall in September
Circumstances of the death
Alfred Thomas Bellingham died in hospital on the 10th November 2024 from an infection that arose from a sacral pressure sore. On the 3rd of September 2024 Mr Bellingham was brought to an outpatient hospital appointment following up on concerns raised by symptoms that may be related to the narrowing of the canal in the bones of his neck. The previous appointment in February had seen Mr Bellingham grow more frail and had lost more of his mobility which had not found its way to the hospital notes.
Mr Bellingham was seated in a hospital wheelchair waiting in a corridor opposite the room where he was to have his appointment. The doctor who was to see Mr Bellingham was running late, by about an hour and in this time a health care assistant checked on him every 5 to 10 minutes. When the last patient had been seen out of his office the doctor spoke to Mr Bellingham apologising for the delay and he returned inside to attend to paperwork before seeing Mr Bellingham. It is likely that Mr Bellingham tried to stand up to make his way into the room for his appointment and in doing so fell. Mr Bellingham had suffered a fracture that required a collar and was treated in hospital before being moved to a Care Home on the 16th October 2024. There was a really serious failure to provide appropriate nursing care to Mr Bellingham in that a preventable sacral pressure sore was allowed to develop to a point where Mr Bellingham had to return to hospital unwell with a pressure sore that had become black/grey in colour with a foul-smelling exudate that made the dressing wet.
Despite every effort by the hospital Mr Bellingham died from a bacteraemia from the infected pressure sore.
Mr Bellingham was seated in a hospital wheelchair waiting in a corridor opposite the room where he was to have his appointment. The doctor who was to see Mr Bellingham was running late, by about an hour and in this time a health care assistant checked on him every 5 to 10 minutes. When the last patient had been seen out of his office the doctor spoke to Mr Bellingham apologising for the delay and he returned inside to attend to paperwork before seeing Mr Bellingham. It is likely that Mr Bellingham tried to stand up to make his way into the room for his appointment and in doing so fell. Mr Bellingham had suffered a fracture that required a collar and was treated in hospital before being moved to a Care Home on the 16th October 2024. There was a really serious failure to provide appropriate nursing care to Mr Bellingham in that a preventable sacral pressure sore was allowed to develop to a point where Mr Bellingham had to return to hospital unwell with a pressure sore that had become black/grey in colour with a foul-smelling exudate that made the dressing wet.
Despite every effort by the hospital Mr Bellingham died from a bacteraemia from the infected pressure sore.
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Report details
- Reference
- 2026-0176
- Date of report
- 12 March 2026
- Coroner
- Andrew Walker
- Coroner area
- North London
Responses identified
Responses identified
1 of 2
All listed responses identified
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Jun 2026 (estimated).
Sent to
- Department of Health and Social Care
- Department of Health and Social Care (changed to NHS England)