Investigation and inquest
On the 17th April 2023 2023, I commenced an investigation into the death of Mrs Hart. The investigation concluded at the end of the inquest on 16 October 2024. The conclusion of the inquest was a conclusion of natural causes.
The cause of death was:
1a) Sepsis,
1b) Acute Limb Ischaemia
1c) Peripheral vascular disease
II) Diabetes mellitus
Circumstances of the death
i) Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023. On the 21 Mar 2023 she started to show signs of having a ischaemic leg. On the 27ᵗʰ march vascular specialist review was requested. There is no vascular team located on the County Hospital, so the review was delayed for 4 days untill the Vascular Consultant was next at the County Hospital.
ii) At the review, the decision was made that Mrs Hart was for palliative care only. She passed away on the 8 April 2023
Coroner’s concerns
1. There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required.