Alice Jean FOX · Prevention of Future Deaths report

On 05 July 2021 I commenced an investigation into the death of Alice Jean FOX aged 90. The investigation concluded at the end of the inquest on 26 May 2023. The conclusion of the inquest was that:

Mrs Alice Jean Fox, known as Jean, died in hospital on 1 July 2021 due to the effects of severe infection resulting from bacterial infection of her surgical site in relation to a partial hip replacement for fracture following a fall at home.

Jean was admitted to Royal Derby Hospital on 7 June 2021 following her fall, and surgery was performed on 9 June. There were no complications during the surgery nor in her post-operative care leading to discharge to Ripley Rehabilitation Hospital where she arrived at about 23:00 on 22 June. Because she arrived so late and out of core hours, she did not have the benefit of the full and usual assessments and she had also been waiting for the transfer for some significant time at the general hospital in its discharge lounge.

The rehabilitation hospital nurse who examined Jean on her arrival noticed the wound site to be red and hot to touch and considered there was a possibility of infection and it was thereafter kept under visual observation. The following morning an advanced nurse practitioner requested routine blood samples be taken as part of the clinical assessment and the blood samples were taken the next day, 24 June, and were available for clinical informed that afternoon but were not reviewed until the next day, 25 June, when raised inflammatory markers were noted and Jean was then transferred back to the general hospital (Royal Derby Hospital) due to infection.

At the general hospital antibiotic treatment was started but Jean was not considered fit to undergo major surgery to remove the partial hip replacement and wash out the wound and end of life care was agreed with her family.

Although the court considered that there had been opportunity to refer Jean back to the general hospital earlier, on the evidence this would not have prevented her death, as even at that earlier point surgery would not have been appropriate due to the high risk of mortality given her comorbidities and frailty.

1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.

2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.