Lynn Moss · Prevention of Future Deaths report

On 31st March 2022, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of Lynn Moss who died on 12th March 2022 at Tameside General Hospital, Ashton-under-Lyne, aged 75 years. The investigation concluded with an inquest which I heard on 28th October 2022.

The inquest determined that Mrs Moss died as a consequence of:-

1a) Sepsis;

1b) Lobar pneumonia;

II) Rhabdomyolysis due to immobility after a fall at home, chronic liver disease, hypertension.

The conclusion of the inquest was one of Accident.

Mrs Moss had been in poor health for a number of years and was effectively housebound. On 11th March 2022, her son found her on the floor at her home, having apparently fallen or collapsed. It was evident to him Mrs Moss was seriously unwell and had probably been on the floor for a considerable period of time.

An ambulance was called and Mrs Moss was taken to Tameside General Hospital where, despite treatment, she sadly died the following day.

Over the course of the inquest, the court heard evidence to the effect that:

1. Despite the seriousness of her condition, Mrs Moss waited over 5 hours from arrival at the Emergency Department until she was fully assessed by a doctor;
2. Mrs Moss waited for around 19 hours in the Emergency Department before a bed was to become available for her on the Acute Medical Unit;
3. Across both units, there were a number of missed opportunities to recognise a deterioration in Mrs Moss’s condition.

The court heard as to a number of steps the Trust has taken locally to reduce risk to patients including increasing initiation of treatment prior to medical review, and making plans to expand the footprint of the Emergency Department.

Notwithstanding such measures, it is a matter of residual concern that systemic problems within the health and social care sectors including difficulty in accessing primary care and delayed discharges combine to lead to persistently high levels of demand on hospital Emergency Departments. Such sustained demand makes timely and effective monitoring of a patient’s condition (and the delivery of urgent treatment where indicated) increasingly difficult, thus creating an ongoing risk of future deaths.