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Investigation and inquest
On 20th January 2022 I commenced an investigation into the death of Ernest Bacon. The investigation concluded on the 26th July 2022 and the conclusion was one of Narrative: Died from sepsis contributed to by the complications of an accidental fall.
The medical cause of death was 1a) Sepsis; 1b) Bronchopneumonia; II) Fractured Neck of Femur, Chronic Obstructive Pulmonary Disease, Ischaemic Stroke
Circumstances of the death
Ernest Thomas Bacon had an accidental fall at his home address. He was admitted to Tameside General Hospital where it was identified he had a fracture to the neck of femur. He was operated on. He had an ischaemic stroke whilst an inpatient. On 16th January 2022 at 19:50, his NEWS score was recorded as 7. He was prescribed fluids but not intravenous antibiotics. The Trust Policy was not followed in relation to intravenous antibiotics being given within 1 hour. He was not given intravenous antibiotics until about 22:38. The decision not to follow the Trust Sepsis Policy was not recognised and not escalated. He continued to deteriorate. On 17th January 2022 he died from Sepsis at Tameside General Hospital.
Coroner’s concerns
1. The Inquest heard that when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOD doctor numbers. This meant that there were a very limited number of doctors available within the hospital when the ward staff asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model;
2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover;
3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis;
4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy. The reason for non-escalation was unclear.
Information checked against the published report and official responses