Frances Margaret Ann Bell · Prevention of Future Deaths report

On 18 April 2012 Dr Peter Dean the former Southend Coroner commenced an investigation into the death of Frances Margaret Ann Bell. The investigation concluded by me at the end of the inquest on 6 March 2014. The conclusion of the inquest was a narrative verdict:-

In the evening of 30 March 2012, Frances Margaret Ann Bell presented at Southend Hospital and she was discharged just after midnight. She was readmitted the next day and on 1 April she underwent abdominal surgery. She died on 13 April 2012. There were very serious failings in the care Mrs Bell received in Southend Hospital. With timely, appropriate care Mrs Bell might have survived.
The medical cause of death was :-

1a) bowel ischaemia
b) internal herniation
11) abdominal adhesions

On 30 March 2012 Mrs Bell presented at Southend Hospital with abdominal pain and she was discharged at just after midnight
On 31 March Mrs Bell was readmitted and she underwent surgery on 1 April
There were very serious failings in the care Mrs Bell received in Southend Hospital

(1) There was no Root Causes Analysis Investigation carried out which would have identified lessons learned and an action plan
(2) There was no input from senior clinical staff at the time of Mrs Bell’s presentation on 30 March
(3) There was an unacceptable delay between Mrs Bell’s readmission on the 31 March and her arrival in theatre on 1 April