Ramona Harbott: Prevention of future deaths report

[REDACTED]  Chief Executive, Barchester Health Care Limited
[REDACTED]  Interim Chief Executive, Care Quality Commission 

Ms Susan Ridge, H.M. Assistant Coroner for Surrey

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and  regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

An inquest into Mrs Harbott’s  death was opened on 14 Mach 2025. The inquest was resumed on 13 November 2025 and concluded on 8  December 2025.       
The medical cause of Mrs Harbott’s death was:
1a. Sepsis 
1b. Pneumonia 
2. Deep Sacral Sore
With respect to where, when and how Mrs Harbott came by her death a narrative conclusion was recorded in Box 4 of the Record of Inquest as  follows: 

Ramona Doreen Harbott was a frail elderly lady who suffered with  dementia. She had a diagnosis of diabetes mellitus and very limited  mobility. She was admitted to the Windmill Manor Care Home on 27  December 2024. At the time of admission, she was assessed as at high risk  of developing pressure sores. Within the first week of her stay in the care  home Mrs Harbott was largely bedbound and remained so throughout her stay. She was not regularly repositioned until sixteen days later on 13  January 2025 once it was noticed that she had developed redness to the  sacral area. On 20 January 2025, the care home recorded that she had  developed what they assessed as a category 2 sacral sore. On 24 January  2025 Mrs Harbott was taken to East Surrey Hospital following advice 
from her General Practitioner after the care home staff had noticed that  she was drowsy, less responsive and deteriorating. On admission to East  Surrey Hospital she had high infection markers, a cough, and fever. Mrs  Harbott was also found on admission to hospital to have a significant  unstageable necrotic sacral pressure sore. Although actively treated for  both the sacral sore and her infection, Mrs Harbott continued to  deteriorate and died in East Surrey Hospital on 19 February 2025. She died from sepsis having contracted pneumonia. The serious sacral sore  which was well established by the time she was admitted to hospital more than minimally contributing to Mrs Harbott’s death as it contributed to  her overall deterioration and lack of physiological resilience.

Mrs Harbott was discharged from hospital to Windmill Manor Care  Home, Oxted on 27 December 2024 because of her increasing care needs.   At this stage she was largely immobile and assessed at high risk of  pressure sores. Mrs Harbott developed a sacral sore whilst in the care  home which by the time she was taken to East Surrey Hospital on 24  January 2025 had become an unstageable necrotic ulcer. She also had a  serious pressure sore to her right heel which was not identified by the  care home until 23 January 2025 and an undocumented deep tissue injury to her other foot. 
Mrs Harbott’s pressure sores were treated (requiring debridement on the ward on several occasions) and contained once she was admitted to East  Surrey Hospital.  But as the court heard, the damage had already been  done before she arrived in hospital.  The evidence showed that both the  sacral sore and the sore to the right heel were well established and  significant before her admission to hospital in January 2025.                                                                        .   

The MATTERS OF CONCERN are:
a. The evidence heard by the court indicated that though the care home  had policies and guidance for the prevention and management of bed  sores that was not followed by on-site care or nursing staff.  Although at  high risk of pressure sores Mrs Harbott was not regularly repositioned  until she had developed a sacral sore. Her skin condition was not  monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time  she was taken to hospital.  The serious pressure sore on the right heel was  not documented until it was seen on 23 January 2025 although it was  likely well established for at least a week.  
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight  however the coroner remains concerned that the matters identified at the  inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.   

 In my opinion, action should be taken to prevent future deaths, and I  believe that the people listed in paragraph one above have the power to take such action.   

You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must  explain why no action is proposed. 

I have sent a copy of this report to the following:
1.  Chief Coroner  
2.  Mrs Harbott’s family