Norman Baxter · Prevention of Future Deaths report

On 28th August 2019, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Norman Baxter, who died at Stepping Hill Hospital Stockport on 8th August 2019 aged 87 years.

The coronial investigation concluded with the inquest which I heard on 18th and 21st February 2020. At inquest, it was determined Mr Baxter died as a consequence of

1) a) Severe sepsis and septic shock

b) Infective exacerbation of Chronic Obstructive Pulmonary Disease and e-coli infection of unconfirmed origin.

II) Type 2 diabetes, probable myeloma, previous hip fracture resulting in girdlestone procedure.

The inquest concluded with a narrative conclusion, to the effect that Mr Baxter died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an e-coli infection. Whilst this is a natural cause of death, it is likely his death was contributed to in part by a previous hip fracture sustained in hospital which ultimately required a girdlestone procedure.

Mr Baxter had been slowing down and showing signs of decline when he was admitted to Stepping Hill Hospital, Stockport in December 2018. There, he underwent investigations amidst a concern he was suffering from myeloma. An incidental finding on one such investigation was an undisplaced subcapital hip fracture which required surgery. A hemiarthroplasty was performed, but Mr Baxter ultimately required a girdlestone procedure having fallen again on the ward and dislocating his prosthetic hip.

Once medically fit for discharge, Mr Baxter required nursing care and as such moved into Lynmere Nursing Home in Stockport. There he settled well essentially, but from time-to-time developed chest infections.

On 7th August 2019, a carer noticed Mr Baxter had become unwell. A Registered Nurse working an agency shift took observations throughout the day, but several hours passed before an ambulance was finally called. Mr Baxter died in hospital the following day.

1. The court heard evidence that, at the time Mr Baxter was cared for at Lynmere, nursing observation charts were not in use. Nursing observation charts, when completed, may assist staff in appreciating an acute episode of illness, or deterioration in a resident’s condition. This may particularly be the case were the observation chart to be used in conjunction with a system such as NEWS2, an aggregate scoring system intended to standardise the assessment of, and response to acute illness.