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Investigation and inquest
On 1st July 2019 I commenced an investigation into the death of Jean Evelyn WAGHORN. The investigation concluded at the end of the inquest on 15th October, 2019. The conclusion of the inquest was a Narrative Conclusion:-
Mrs. WAGHORN died of pneumonia which developed when she was in hospital receiving conservative care for fractures to her neck sustained when she fell at home and hit her head on the floor. This lady was transferred between hospitals three times in just over 48 hours.
I FIND that the first transfer late on 23rd June 2019 (the day of her fall) was appropriate - she had been diagnosed with a fractured neck at Haywards Heath Local hospital and needed assessment and care at the South East Trauma and Spinal Centre in Brighton.
I FIND that the next two transfers were not appropriate. I cannot say that they contributed to her death however she developed the pneumonia from which she died within 12 hours of her arrival back in Brighton on the 25th June. This was quickly recognised and appropriately treated. Sadly however, Mrs. WAGHORN did not make a recovery. She died peacefully on 29th June 2019.
Circumstances of the death
See Record of Inquest
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) Unnecessary and inappropriate transfers between the Royal Sussex County Hospital, the Princes Royal Hospital and the Royal Sussex County Hospital.
(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored.
(3) I have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by ████████, three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?