Susan Sterland · Prevention of Future Deaths report

On 8 January 2019 I commenced an investigation into the death of Susan Sterland, age 76. The investigation concluded at the end of the inquest on 23 January 2020. The conclusion of the inquest was that Susan Sterland died of undiagnosed intestinal obstruction.

Susan Sterland was brought by ambulance to the emergency department of Kettering General Hospital on 29th December 2018. She had intestinal obstruction which was not diagnosed.

Ms Sterland was diagnosed with constipation and admitted to the emergency decisions unit (EDU). The intention was to admit her to the medical ward but there were no available beds and so she remained on EDU for two nights. During the time she was in hospital she was seen by two experienced Advanced Care Practitioners (ACP) and by one junior doctor (FY1). She was never seen by senior doctor. During the day on 30 December she showed some signs of deterioration. Her condition then rapidly deteriorated during the late evening of 30 December 2018 but her care was not escalated. She collapsed and died early on 31 December 2018.

This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December, there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor. If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome.

The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.