Roger Phelps · Prevention of Future Deaths report

On 9th November 2020 I commenced an investigation into the death of Roger Phelps. The investigation concluded on the 27th August 2021 and the conclusion was one of narrative- Died from sepsis contributed to by endocarditis not diagnosed until after his death in combination with Covid-19 contracted whilst an inpatient at Tameside General Hospital.
The medical cause of death was 1a Sepsis 1b Endocarditis and Covid-19 infection II Congestive cardiac failure, hypertension, type 2 diabetes mellitus, aortic stenosis with left ventricular hypertrophy

Roger Phelps was seen at Tameside General Hospital on 4 occasions in October 2020 with deteriorating cardiac function. He was not referred on the acute heart pathway. Following his admission on 21st October it was recognised that he needed to be treated in the Heart Unit. A bed was not available, and he stayed on a general medical ward until 29th October. He had signs of significant cardiac failure. He contracted Covid-19 from another patient. At the time the trust were swabbing in accordance with PHE guidance.
The results of the swabs were regularly taking in excess of 48 hours which increased the risk of exposure in patients to Covid-19. A swab of 29th October reported on 1st November indicated he had Covid-19. He deteriorated rapidly from 29th October. He also exacerbated his underlying conditions including his cardiac failure. He exhibited signs of sepsis.
He was treated but continued to deteriorate and died at Tameside General Hospital on 4th November 2020. Post-mortem examination found he had died from sepsis. He was found at post-mortem to have developed endocarditis which also contributed to his death.

The inquest heard that whilst the trust were following PHE/NHS guidance in relation to regularity of swabbing of inpatients it was regularly taking in excess of 48 hours for swab results to be returned to the trust. The impact of the delay was that infectious asymptomatic patients were remaining on non Covid wards for some days and spreading infection to other patients.
The trust where Mr Phelps was a patient had now resolved the issue of delay results by buying additional on-site testing machines and results were back within hours rather than days.
It was unclear from evidence given at the inquest whether the issue of delayed results had been addressed by other trusts in a similar way or if the risk remained to other patients in other trusts.