Barbara HOLLIS · Prevention of Future Deaths report

On 04 March 2022 I commenced an investigation into the death of Barbara HOLLIS aged 71. The investigation concluded at the end of the inquest on 24 August 2022. The medical cause of death was:
1a Fat Embolism
1b Left Total Knee Replacement Operation
2 Acute Myocardial Infarction

The conclusion of the inquest was that: Mrs Hollis died from a rare but recognised risk of an elective operation

Mrs Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications. After her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 hours and were told that immediate clinical intervention was needed. The agreed hospital to hospital transfer pathway was not followed. A two hour delay in ambulance attendance was notified. Mrs Hollis continued to deteriorate and the ambulance service was telephoned again at 21.17 hours.
The ambulance attended at 21.27 hours and Mrs Hollis was taken to the High Dependency Unit at the Norfolk and Norwich University Hospital. Her condition continued to deteriorate and Mrs Hollis died in the early hours of the 23 February 2022.

1. EEAST were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect.
2. The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes
3. At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours
4. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service
5. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur