Philip John UNWIN · Prevention of Future Deaths report

On 05 April 2024 I commenced an investigation into the death of Philip John UNWIN aged 68. The investigation concluded at the end of the inquest on 18 February 2025. The conclusion of the inquest was that: Natural Causes

Mr Unwin was a 68 years old gentleman who was admitted to Royal Stoke University hospital on 2 April 2024 at 00:45 due to fever, shortness of breath and chest pain. He was commenced on broad spectrum antibiotics within an hour of his arrival for suspected sepsis due to Urinary Tract Infection although it was subsequently confirmed that sepsis was secondary to pneumonia.

He remained in the resus area of the Emergency Department despite a progressive deterioration in his condition and escalations from the nursing team to the medical team for him to be reviewed.

Transfer to ICU was not initiated until approximately 14:30 at which time he was noted to be acutely unwell and in peri arrest. After being transferred to ICU at approximately 16:00 supportive intervention including sedation, ventilation and vasopresser medication failed to reverse his condition and he passed away in hospital on 3 April 2024 due to multi organ failure secondary to pneumonia.

Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death).

As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.

However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance.

The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect.