Anne HAWKES · Prevention of Future Deaths report

On 3 August 2023 I commenced an investigation into the death of Anne HAWKES. The investigation concluded at the end of the inquest . The conclusion of the inquest was

Narrative conclusion.

Mrs Hawkes died in Rotherham District General Hospital on the 15th July 2023 as a consequences of multi organ dysfunction due to an infected hip joint. The infection occurred due to surgical wound breakdown because of pressure caused by fluid overload as a result of poorly managed cardiac failure.

Mrs Hawkes was admitted to Rotherham Hospital on the 3rd of May 2023 following a fall at home. She had sustained a fracture neck of femur and underwent surgical fixation the following day. Mrs Hawkes initially recovered well and was medically fit for discharge by the 11th of May 2023. Mrs Hawkes remained on the orthopaedic ward whilst awaiting social care input prior to discharge. Whilst on the orthopaedic ward, her cardiac failure was not monitored by way of fluid balance charts or daily weights. Her weight on admission had been estimated at 72 kilogrammes, by the 22nd May 2023, her weight had increased to 104.5 kilogrammes.

This increase in weight was not acted upon until the 17th of May 2023 when a referral to cardiology was made, by this time she was very unwell with fluid retention, hyponatremia and deteriorating renal function. Mrs Hawkes was seen by a specialist Cardiac failure nurses on the 22nd May and immediately commenced on intravenous medication to deal with this fluid excess. Mrs Hawkes was transferred to the cardiology ward on the 25th of May 2023.

Whilst on the cardiology ward her weight gradually reduced to 83 kilogrammes. On the 26th June 2023, she was considered stable in relation to her cardiac failure. On the 3rd of June 2023 the surgical wound started to break down. All witnesses at the inquest agreed that the wound breakdown was most likely due to this fluid overload putting pressure on the wound causing it to breakdown. There was no evidence of infection in or around the wound at this time.

Despite the wound starting to break down on the 3rd of June, the referral to tissue viability was not made until the 29th June 2023. By this time, tissue viability were unable to assist due to the advanced state of dehiscence and they made a referral to the orthopaedic surgeons. A surgical washout was declined by Mrs Hawkes, therefore the wound was managed with dressings and antibiotics. She deteriorated and died on the 15th of July 2023.

(1) The delayed cardiology referral whilst Mrs Hawkes was on an orthopaedic ward led to sub-optimal management of her cardiac failure which in turn is implicated in her death. There is no procedure in place at the Trust for Clinicians to automatically refer in-patients with known cardiac failure to cardiology for expert management.

(2) The lack of communication between services within the Trust (surgery, cardiology and tissue viability) led to a delayed and incohesive approach to the wound management.