Jacqueline Frances O'BRIEN · Prevention of Future Deaths report

On 07 November 2025 I commenced an investigation and opened an inquest into the death of Jacqueline Frances O'BRIEN aged 77. The investigation concluded at the end of the inquest on 24 June 2026. The conclusion of the inquest was that Mrs. O'Brien "died from natural causes, to which injuries sustained in an accidental fall at home contributed."

Between 17.10.25 and 3.11.25 Mrs. O’Brien was treated at Worcestershire Royal Hospital for head and spinal injuries resulting from an accidental fall down stairs at home. On 3.11.25 she was discharged to Pershore Community Hospital for further rehabilitation at a time when she was becoming increasingly unwell with an intra-abdominal infection, and had to be transferred back to Worcestershire Royal Hospital that same night. Despite treatment, her condition continued to deteriorate, and she declined and died there on the evening of 4.11.25.

On 29.10.25 Mrs. O'Brien's Liver Function Test ( LFT ) results had been abnormally high ( Gamma GT: 545, ALT: 200 ). The plan was to repeat those tests a few days later.
At around 2300hrs on the night of 2.11.25 Mrs. O'Brien was transferred to the Pathway to Discharge Unit ( PDU ) at Worcestershire Royal Hospital with a view to discharge for further rehabilitation to Pershore Community Hospital. At the time of her transfer to the PDU, it was recorded in her notes that she had been experiencing constipation pain for the previous hour, and had passed loose stools.
Her LFTs were repeated that morning, and although had lowered, were still considered abnormally high ( Gamma GT: 387; ALT: 122 ). At 1200hrs on 3.11.25 a trauma and orthopaedic doctor recorded that Mrs. O'Brien's discharge could not go ahead because of these still abnormal LFT results. The note continues: "Escalated the problem to the capacity team, and they instructed that the discharge will proceed."
At 1230hrs it is recorded that Mrs. O'Brien was re-assessed by the doctor and a consultant and "they said the discharge will carry on."
It was agreed by the consultant who gave evidence at the inquest, and by the Trust's legal representative, that thereafter between 1230hrs and Mrs. O'Brien's departure for Pershore at 2025hrs that evening, there is no evidence of any further checks or observations being carried out.
In fact, when Mrs. O'Brien was seen on the PDU by family members that same afternoon, it was clear to them that she was in a great deal of pain and distress. They raised their concerns with staff on the PDU, who assured them that she was alright. No member of staff appears to have acted on those concerns, and ensured that Mrs. O'Brien was checked.
Those who transported Mrs. O'Brien to Pershore reported to staff there that she "had been in pain on transfer". On her arrival at Pershore at 2100hrs, it was clear to staff there and to an out of hours GP who was called to examine her, that she was in severe pain and very unwell, with a National Early Warning Score ( NEWS ) of 5. An ambulance was called to transfer her back to Worcester, and the paramedics recorded at 0111hrs that her NEWS score had risen to 10.
I am therefore concerned at how staff on the PDU at Worcestershire Royal Hospital failed:
(a) for some 8 hours to carry out any checks or observations on a patient who was clearly becoming very unwell; and
(b) to follow up concerns raised by Mrs. O'Brien's family about her condition on the afternoon/evening of her discharge.
I have found, as a matter of fact that, had they not so failed, they were bound to have noticed how unwell she was becoming and her transfer to Pershore would probably not have taken place. This represented a missed opportunity to provide earlier treatment which may have prevented her dying when she did.