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Investigation and inquest
On 4 March 2015 I commenced an investigation into the death of Caroline Robey. At inquest held on 29 September 2015 my conclusion was natural causes contributed to by neglect
Cause of death
1a Multiple organ failure
1b Bronchopneumonia
1c Group A Streptococcal infection
Circumstances of the death
At inquest the determinations were that Mrs Robey was a fit 34 year old working mother when she became unwell. She presented on 6 separate occasions over a course of 5 days to the community health care service providers, including her General practitioner, the urgent care centre and the ambulance service.
She was diagnosed initially with a viral infection and then diarrhoea and vomiting, but advised to remain at home. An ambulance was then summoned and she was taken to the Emergency Department at Leicester Royal Infirmary with a pre-alert for sepsis as a time-critical patient. Despite all possible interventions on her arrival in ED and then ICU she did not survive the Group A streptococcal infection and evolving sepsis and died the following day.
Evidence suggested that earlier intervention, on the balance of probabilities, would have treated the infection and prevented this death.
Coroner’s concerns
1. No sepsis screening tool was being used by the community health care providers, and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment.
2. A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this case.
3. Inadequate note was taken of the number of different attendances Mrs Robey had initiated despite previous good health, and there was no suggestion she was a frequent attender or had ever sought medical assistance inappropriately.
Information checked against the published report and official responses