Linda Christine FARMER · Prevention of Future Deaths report

On 22 September 2023 I commenced an investigation into the death of Linda Christine FARMER aged 67. The investigation concluded at the end of the inquest hearing on 2 April 2025 at Northamptonshire Coroner’s Court.

The medical cause of death was:
I(a) Bronchopneumonia
(b)
(c)
(d)
II Liver cirrhosis with hypoalbuminemia, COPD, poor nutritional status

The Box 3 findings of the record of inquest were:

Linda Farmer died at Northampton General Hospital on 22 August 2023. She had been admitted on 19 August, very unwell, and was swiftly place on a palliative pathway. She died as a result of bronchopneumonia, her death being hastened by other underlying medical conditions and her poor nutritional state.

She had had a previous admission to the hospital from 27 June – 16 August. Throughout this admission, her albumin levels had been low, and were consistently falling. At the time of her discharge on 16 August, the cause of this low albumin had not been fully investigated, but this was not probably causative. For at least the four weeks before her discharge on 16 August, Mrs Farmer’s oral intake was very low.

Additional information for the purpose of this report is that:

When Mrs Farmer was re-admitted on 19 August, the clinicians caring for her identified concerns with the care provided in the admission from 27 June – 16 August, namely, in relation to the low albumin levels. These concerns were notified to the Family, and raised with the Medical Examiner at the time

Not investigating care concerns raised by clinicians employed by the Trust in August 2023, compounded by not following the recommendation in the Trust's own Structured Judgement Review (2024) to carry out a "detailed investigation" into the care concerns raised. The absence of such investigations, having been identified by Trust processes as having been recommended, means that the care concerns raised have not been investigated, and any underlying system issues contributing to these have not been identified or resolved. This means they are at risk of occurring again, putting patients' lives at risk.