Catriona Ellen Martin · Prevention of Future Deaths report

On 19/01/2021, an investigation was opened into the death of Catriona Ellen Martin

The investigation concluded at the end of the inquest on 23/11/2023.

The conclusion of the inquest was recorded as a narrative conclusion in the following terms:

Catriona Ellen Martin was admitted to hospital on 05/12/2020 with autoimmune encephalitis. The treatment plan was not adhered to because Catriona was not provided with adequate nursing care which resulted in a failure to observe her, failure to administer medication and caused her to develop dehydration, acute kidney injury and uncontrolled seizures. This resulted in Catriona’s death at the Grange University Hospital, Llanfrecha on 25/12/2020. Catriona Ellen Martin died from the effects of autoimmune encephalitis contributed to by neglect.

The medical cause of death was:

1a) Autoimmune encephalitis

The circumstances of Catriona’s death are best described in the narrative conclusion. Throughout her admission Catriona required 1:1 nursing care which, apart from a short admission to ITU between 08/12/2020 and 15/12/2020, Catriona did not receive. The nursing staff relied on Catriona’s mother to ensure that Catriona received the fluid and medication she required. Catriona’s mother continuously advised the nursing staff that she was unable to ensure that Catriona was receiving fluid and medication, however no assistance was given, and Catriona went into a fatal decline.

I found that Catriona’s death would have been prevented if 1:1 nursing care had been provided.

At the inquest I determined that the level of care that Catriona’s mother was expected to provide was unacceptable but was informed that there are no guidelines to establish the level of delegation of nursing duties in such circumstances, and the requirement of the nursing team to not only continue to supervise care but to support and intervene as required.