Mrs Joan Robinson · Prevention of Future Deaths report

On 3rd November 2022, I opened an inquest into the death of Mrs Joan Robinson, who died at Tameside General Hospital, Ashton-under-Lyne on 30 June 2022, aged 88 years. The investigation concluded at the end of the inquest which I heard on 23rd November 2022.

A post mortem examination concluded Mrs Robinson died as a consequence of:-

1a) Congestive cardiac failure;

b) Ischaemic and valvular heart disease with superimposed cervical spinal trauma following a fall.

The conclusion of the Inquest was one of Accident.

Mrs Robinson was admitted to hospital having sustained multiple cervical spinal fractures in a fall at her home. Following consultation with the regional neurosurgical centre, Mrs Robinson was treated conservatively by means of immobilisation.

Shortly after her admission, Mrs Robinson developed acute confusion, and reported pain in her throat. She was noted by nursing staff to have a poor oral intake, and eventually referred for a dietician review. Whilst in hospital, Mrs Robinson lost her ability to swallow safely, and due to her injuries and the treatment for it, difficulties were encountered in siting a nasogastric tube.

Having exhibited signs of atrial fibrillation just over a week into her admission, Mrs Robinson started showing signs of congestive cardiac failure. Her condition worsened with increasing oedema, acute kidney injury and a raised white cell count and a decision was made to institute palliative care.

1. The court heard evidence that, despite training on the Malnutrition Universal Screening Tool being regarded by the Trust as ‘essential’, the completion rate of training within the organisation is currently just 58.74%;

2. Connected with the above, it is a matter of concern that whilst the Trust describes this training as ‘essential’ it is not deemed mandatory for completion by certain staff groups such as nurses and healthcare assistants;

3. It is a further matter of concern given the importance of adequate nutrition and hydration as a part of basic patient care, that the Trust’s own internal investigation into the care and treatment provided to Mrs Robinson has found that the ‘Nutrition and Hydration Committee [is] not consistently supported, held or attended’.