Margaret Rose Toye · Prevention of Future Deaths report

On the 22nd April 2021 I opened an investigation touching upon the death of Margaret Rose Toye, aged 81 years old. I opened an inquest on the 5th May 2021. The inquest concluded on the 21st December 2021.

The conclusion of the inquest was Natural Causes, the record of inquest stated:

“On the 10th April 2021 Mrs Margaret Rose Toye sustained an unwitnessed fall in the community and suffered a left neck of femur fracture. Following surgery to repair the fracture on 12th April 2021 Mrs Toye received ward based care and on 20th April she died following a cardiac arrest.”

The cause of death was recorded as;

1a Cardiac Failure
1b Ischaemic Heart Disease
1c Coronary Artery Atherosclerosis
II Fractured Left Neck of Femur

Following a fall in the street on 10th April 2021, Mrs Toye was taken by ambulance to hospital where she underwent a surgical repair of the fracture on 12th April 2021. Despite recovering from surgery well, whilst care for on the ward Mrs Toye sustained a cardiac arrest on 20th April 2021.

1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.

2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.