A mother died after ‘significant failures and missed opportunities’ at the NHS hospital where she was treated, an inquest has ruled.
Tracey Farndon, 56 died just hours after visiting her local A&E department in Birmingham, after NHS staff failed to identify and escalate the signs of sepsis.
This week, a coroner told the inquest that if staff at Birmingham’s Queen Elizabeth Hospital had intervened earlier, Tracey would not have gone into cardiac arrest and died that morning.
Coroner Louise Hunt said ‘gross failings’ contributed 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.
At present, CQC reports show that Queen Elizabeth Hospital in Birmingham requires improvement overall, with concerns raised about the safety and responsiveness.
The inquest heard how Tracey had sought help at A&E after suffering from symptoms including vomiting, fatigue, worsening pain in her back and legs and diarrhoea for three days.
But when she visited Queen Elizabeth Hospital, the A&E was busy and understaffed, and basic tests were not sufficiently conducted.
During the inquest, it was explained that a blood pressure reading was not obtained, and 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 or escalated by staff.
The inquest also heard how 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.
But during the seven hours Tracey was in A&E, she was never given a full assessment and was only assessed from a pain and medication perspective. The inquest also heard how 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.”
NHS failures
The post-mortem into Tracey’s death revealed that 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.
The failures to appropriately measure and record her blood pressure on arrival, and also calculate the NEWS2 score, were also listed as gross failures amounting to neglect.
A lack of staffing was also highlighted as an ongoing issue.
Concluding the case, Coroner Louise Hunt said 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.”
What is medical negligence?
Healthcare professionals have a duty of care to their patients and a responsibility to provide prompt and effective treatment. If your injury was missed or you experienced a delay in diagnosis, then this may constitute medical negligence and you may be entitled to compensation.
Here at Oakwood Solicitors we have firsthand experience in dealing with people whose lives have been changed by medical negligence. Bringing an A&E negligence claim has allowed our clients to receive the financial support that is needed to aid in their recovery and subsequent treatment.
Medical negligence in A&E departments
On average 68,000 adults and children attend A&E on a daily basis. Accident and Emergency Departments are the busiest part of the hospital.
An array of injuries are seen in A&E Departments from cuts and bruises, fractures, to deadly infections and near fatal injuries. It is not a simple area of clinical negligence due to the many different possible injuries that a patient may present with.
Unfortunately, it is often the case that injuries go undetected or else are misdiagnosed within the A&E department. On attendance at A&E, the treating medical professional has a duty to carry out the appropriate physical examination, diagnose any injury and treat accordingly.
They may also need to refer you to a specialist department so that you can receive further treatment. A&E negligence therefore commonly occurs as a result of one or more of the following:
- Incorrect medication prescribed
- Incorrect treatment provided
- A delay in appropriate treatment
- Inadequate patient examination or referral
- Misinterpretation of radiology or examination results
- Failure to admit patients for further treatment
- Failure to recognise serious symptoms or missing high risk conditions
This can result in the injury becoming more difficult to treat, it may require more invasive treatment going forwards, it may cause increased pain and suffering or it may cause you to develop other connected health problems.
How to make a medical negligence claim
If you feel that an A&E practitioner has misdiagnosed, failed to refer, not fully investigate or did not provide you with the correct treatment then you could be entitled to compensation. The team at Oakwood Solicitors will be able to give you free advice on the prospect of your case and whether you would be eligible to make a claim.
Further reading
Medical misdiagnosis or delay – Oakwood Solicitors
WHAT TO DO NEXT
Get in touch today for a no-obligation consultation. Choose one of the methods on the right-hand side of this page, or call us on 0113 200 9720 to find out how we can help you.
Jade Glover is a Solicitor in the Medical Negligence team. She has worked for the company for over 9 years and completed her training during that time. She has specialised in Personal Injury clai…
Medical Negligence Team – Case Studies Showcase
Here is a collection of recent case studies from our Medical Negligence department, showcasing not only the variety of matters they help to resolve, but also the figure awarded to the client upon …
View
