A ‘fit and healthy’ mother died after ‘significant failures and missed opportunities’ at the hospital where she was treated.
Tracey Farndon died only hours after admission to the A&E department at Queen Elizabeth Hospital Birmingham.
The grandmother, 56, was pronounced dead in the early hours of April 25 last year following a failure to identify and escalate signs of sepsis on arrival properly.
This delayed potentially life-saving treatment, an inquest concluded.
Had staff intervened earlier, Tracey would not have gone into cardiac arrest and died that morning, coroner Louise Hunt told the inquest on Thursday.
Hunt outlined ‘gross failings’ contributing to Tracey’s death, which was attributed to natural causes, contributed to neglect and delayed diagnosis.
Two Prevention of Future Death (PFD) reports will follow Tracey’s inquest: one to the Department of Health and Social Care; and one to University Hospitals Birmingham NHS Foundation Trust to highlight how hospital staffing issues must be improved.
Tracey had sought help at A&E after feeling unwell for three days, with symptoms including vomiting, fatigue, worsening pain in her back and legs and diarrhoea.
The A&E was busy and understaffed, the inquest heard. Basic tests were not sufficiently conducted, for instance, a blood pressure reading was not obtained.
Its significance was not detected by medical staff as Tracey’s blood pressure was likely too low for a reading to be picked up by the machine. However, this was not investigated nor escalated by staff.
Tracey’s blood pressure reading would likely have resulted in a National Early Warning Score (NEWS2) of two to three – prompting an escalation of care. This would have included blood tests, detecting developing sepsis and leading to a Sepsis 6 treatment pathway.
During the seven hours Tracey was in A&E, she was not given a full assessment and was only assessed from a pain and medication perspective.
Observations should have been repeated frequently as Tracey was deteriorating and was severely dehydrated, which was not detected. She went into cardiac arrest and died that morning with her partner, Tom Parkin, and daughter, Jess Sulmina, by her side.
Speaking after the inquest, Jess, who was pregnant when her mother died, said: ‘I am relieved by the coroner’s decision today and that I can finally feel a sense of justice following this shocking and devastating tragedy.
‘I am glad that the University Hospitals Birmingham NHS Foundation Trust has had to give answers for what happened the day my mother died and that there is a clear account of the deficiencies in the Emergency Department.
‘What my mother went through in the final hours of her life was truly horrendous and I am completely heartbroken about the lack of care she experienced when she needed it most. I am glad that the coroner has recognised the seriousness of what happened given that she concluded that my mother’s death was contributed to by gross failures amounting to neglect.
‘I am still processing the whole tragedy, and the feelings of anger and disbelief are still with me to this day. Before I knew it, she was gone; I never got the chance to say goodbye.
‘I was pregnant at the time, and it is gut-wrenching to think about the memories that could have been made with my mother had things turned out differently. I sincerely hope that lessons are learned so that no other family has to go through what we’ve been through.’
Tracey’s post-mortem revealed her cause of death was likely septic shock, developed from pneumonia. Hunt found the delay in treatment escalation was a contributing factor to Tracey’s cardiac arrest and subsequent death.
Failures to appropriately measure and record her blood pressure on arrival, and also calculate the NEWS2 score, were listed as gross failures amounting to neglect.
A lack of staffing was also highlighted as an ongoing issue. Witnesses from the hospital said measures were being taken to ensure this improves. Apologies were issued on behalf of University Hospitals Birmingham NHS Foundation Trust for the failings.
Hunt concluded that proper care could have saved or prolonged Tracey’s life. She said that ‘it wasn’t appreciated [by the hospital staff] that she was suffering from sepsis’, and she acknowledged the importance of the Trust identifying its failures.
Recording a narrative conclusion, Hunt said: ‘Tracey died from natural causes contributed to by a delay in diagnosis and treatment.
‘Her death was contributed to by neglect. I am still concerned about a genuine lack of understanding about sepsis.
‘It does seem to me that there was a particular lack of understanding here because it was not considered by anybody until after her death.’
Leigh Day associate solicitor Ella Cornish, who represented Jess and Tracey’s family alongside clinical negligence partner Sanja Strkljevic, said: ‘The evidence at the inquest has today recognised the substantial failings in the care that was provided to Tracey.’
‘It has been very distressing for Tracey’s family to hear that her life could have been prolonged if the proper care had been provided to her when she attended Queen Elizabeth Hospital.’
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