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Investigation and inquest
On 24 February an investigation commenced into the death of Lina Piroli, age 93 years. The investigation concluded at the end of the inquest on 1 December 2025. I made a determination at inquest that Lina Piroli suffered a multifactorial fall contributed to by naturally occurring age-related disease processes and an E. coli infection.
Circumstances of the death
Lina Piroli presented to the Whittington Hospital on 1 February 2025 with a two week history of feeling unwell, including a dry cough. Whilst a chest X-ray was clear, she had a raised heart rate, raised respiration rate, a temperature and slightly raised inflammatory markers. She was treated with IV antibiotics and fluids for a suspected chest infection and was discharged home on oral antibiotics in the early hours of 2 February. Microbiology culture results were awaited. Lina re-presented to A&E by ambulance that evening following a fall down stairs at home. She was found to have an unstable fracture of C2 and a stable fracture of L1. Whilst in A&E, microbiology results were returned indicating an E.coli infection which was later confirmed, although location of the infection was never established. She was already on the correct antibiotics and so treatment continued. After a long stay in A&E due to lack of a bed, Lina was transferred to a ward. Her pain and swallow were difficult to manage and she was presenting with delirium. She was unable to tolerate the hard collar and did not respond clinically to ongoing antibiotic treatment. Due to her age and frailty, her treatment became focused on comfort and she died whilst still an inpatient at the Whittington Hospital on 20 February 2025.
Coroner’s concerns
When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
Information checked against the published report and official responses