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Investigation and inquest
On 12/10/2023, an investigation was opened touching upon the death of Kay SIMMONDS
The investigation concluded at the end of the inquest on 7/8/2024
The conclusion of the inquest was recorded as
Narrative Conclusion:
“Kay Simmonds attended the Grange University Hospital in Llanfrechfa on 21/7/2022 with signs of sepsis, arising from an infected central line used for haemodialysis. On 22/7/2022, Kay developed septic shock and should have been admitted to the Intensive Care Unit (ITU). Kay was erroneously transferred to the University Hospital of Wales where there were no ITU beds available. Overwhelmed by sepsis, Kay collapsed and died at the University Hospital of Wales on 22/7/22 at 23:45 hours”
The medical cause of death was:
1a) Sepsis
1b) End Stage renal Failure (Treated)
1c) Type 2 Diabetes Mellitus
2. Ischaemic Heart Disease.
Circumstances of the death
These are described in the Narrative Conclusion in Box 3.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements.
The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk.
