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Coroner writes to King's Lynn hospital expressing concerns over woman's care prior to her death




A coroner has written to Lynn’s Queen Elizabeth Hospital to express concerns about a woman’s care prior to her death.

The inquest, held on Friday, was told that 60-year-old Ann Todd died at the QEH on February 18 this year.

The court heard that Ms Todd, who had previously had chemotherapy treatment at the hospital, was admitted to the QEH in January due to bowel obstruction.

A coroner has written to the QEH to express her concerns related to a patient's care prior to her death.
A coroner has written to the QEH to express her concerns related to a patient's care prior to her death.

A PEG tube was inserted into her stomach to help bypass her obstruction.

Ms Todd was discharged to Swaffham Community Hospital for rehabilitation, but she was re-admitted to the QEH in late January due to continued illness.

In a statement read to the court, Ms Todd’s friend Amanda Brindle said when she visited Ms Todd in hospital, she found that she had abdominal wounds which were “oozing out of the dressing” close to the PEG site.

The inquest heard that Ms Brindle requested the dressing be looked at, as Ms Todd was “not able to recollect the last time it had been attended to”.

Ms Brindle said, as the nurse “struggled” with the dressing, she removed the bandage herself.

She added that, in February, Miss Todd stated her wishes to return home with a package of care in place, to allow her to die at home.

Ms Brindle said: “I’m aware that Ann’s remainder of life would have been short but her wellbeing could have been improved.”

Dawn Slack, lead cancer nurse, said, in a statement read to the court, that on the weekend prior to Ms Todd’s death, her wound was found to be infected.

She said the nursing team requested that an on-call doctor assess the wound, but they declined.

“Due to the patient being on end of life care, they felt it was not appropriate for her to be assessed that day and felt it was more appropriate to wait until Monday,” she added.

Ms Todd died at the QEH on Tuesday, February 18 after her condition deteriorated.

Area coroner for Norfolk Yvonne Blake said Ms Todd died of renal failure which developed as a result of sepsis due to infection around a PEG.

She had a reduced immune system as a result of chemotherapy due to ovarian cancer. Ms Blake concluded that Ms Todd died of natural causes.

The coroner said she would write a regulation 28 report to the QEH to prevent further deaths.

She said: “I have already written to the QEH expressing my concerns that the on-call doctors would not attend to Ms Todd on the basis that she was at the end of her life and they felt it could wait until Monday.

“This lady had an infection. Even though she would not be resuscitated, infections and pain are still treated in these circumstances. As it turns out, nurses did give antibiotics in order to address the PEG.”

Ms Blake said she was also concerned by statements describing staff on the ward Ms Todd was on as having a language barrier, and that nurses had to be shown how to change a wound dressing.

“This is unsatisfactory and it matters not whether somebody is at the end of life or not,” she added.

“I will be writing to the hospital further about this, although I will give them an opportunity to reply, I’m minded to write a regulation 28 report, a report that coroners can write to prevent further deaths.

“I’m quite clear she was terminally ill, but another patient who was not terminally ill and had an infection could die if not attended to. I’m very concerned about the state of affairs.”

Dr Frankie Swords, QEH medical director, apologised to Ms Todd’s family.

She said: “Ensuring we provide the very best quality care to all our patients, regardless of the stage of life they are at is our top priority.

“We are deeply concerned that it appears that we have not met the high standards we would all expect on this occasion for Ms Todd. We are now working through exactly what happened to ensure that we learn from any mistakes made, and to ensure it does not happen again.

“We would like to offer our sincere condolences and apologies to the patient’s family at this difficult time.”


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