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Investigation and inquest
On 29 May 2025 I commenced an investigation into the death of Barbara Wingate. The investigation concluded at the end of the inquest . The conclusion of the inquest was
A narrative "She died as a consequence of injuries sustained following a fall contributed to by avoidable delays in diagnosing and treating her pelvic fractures."
1a Multiple Organ Failure
1b Hypoxic Cardiac Arrest with Aspiration
1c Multiple Fractures
1d Fall
II Ischaemic Heart Disease, Atrial Fibrillation, heart Failure
Circumstances of the death
Barbara Wingate was a 71 year old woman with a past medical history of hypertension, atrial fibrillation and cardiac failure and was on anticoagulants. She fell at home on 18 May 2025 and an ambulance was called who took her to Medway Maritime hospital having pre-alerted the hospital and classifying her as a "silver trauma". She was seen in the emergency department just before midnight but there were no beds in the resuscitation department and she was instead taken to the Rapid Assessment Unit when she should have gone to the resuscitation department and a full trauma call initiated. She was assessed by a nurse but only seen by a doctor just after 01.30 am. An x-ray revealed some spinal abnormalities and the following morning around 08.30 she was in significant pain and pelvic imaging was suggested. She was admitted under the care of the medical team but the pelvic x-ray was not undertaken before she collapsed around 4 pm that afternoon. Imaging revealed multiple pelvic fractures and the major haemorrhage protocol was commenced. She suffered a cardiac arrest and was intubated and ventilated and a return of spontaneous circulation achieved. She was stabilised and transferred to Kings College Hospital around 22.00 by which time she was hypoxic and hypotensive despite inotropic support and intubation and ventilation. She was transfused with blood and blood products, stabilised and transferred to Intensive Care. She died on 21 May 2025 as a consequence of multiple organ failure due to hypoxic cardiac arrest with aspiration in turn due to bleeding and pain from her multiple fractures following her fall.
Coroner’s concerns
Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust. The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
Information checked against the published report and official responses