Coroner's prevention of future deaths report says Cynthia Gilbert developed pressure ulcers and septicaemia in hospital and died, in part due to lack of adherence to her care plan, which included repositioning every 1-2 hours. A tissue viability nurse told the coroner’s inquest that ward staff at Somerset NHS Foundation Trust were repeatedly warned about the inportance of these measures, but the warnings were not heeded. The trust says it will take action to make improvements in care.