Irene Annie Davies · Prevention of Future Deaths report

On 8th March 2022 I commenced an investigation into the death of Irene Annie Davies. The investigation concluded on the 19th August 2022 and the conclusion was one of Narrative: Died from Natural Causes contributed to by the complication of an accidental fall and an infected nephrostomy tube.

The medical cause of death was 1a) Congestive Cardiac Failure on the background of Urinary Tract Infections; II) Bleeding from a fall, Infected Nephrostomy, Atrial Fibrillation, Extra- Articular Fracture

Irene Annie Davies had multiple underlying health issues including congestive cardiac failure. She had a nephrostomy as a consequence of renal stones. An operation for renal stones had been delayed due to a combination of factors including delays and backlogs in elective surgery. She had repeated urinary tract infections as a consequence of the nephrostomy. On 1st March 2022 she had an accidental fall at her home address. She sustained significant lacerations and bled profusely. An ambulance was called, she was identified as requiring a category 2 response. Due to demand it was in excess of an hour before an ambulance attended at her home address. She was taken to Stepping Hill Hospital. She was found to have a fracture of the vertebrae and to have symptoms of a urinary tract infection. She was treated with antibiotics. On 2nd March 2022 at Stepping Hill Hospital she was found unresponsive.

1. The Inquest heard that Mrs Davies was identified as requiring surgery and the discomfort she was due to the renal stones and from the nephrostomy. Pre-COVID the wait time for surgery was 18 weeks. It had risen to 2 years at the time she required the surgery due to challenges in providing elective surgery during COVID. The Inquest heard that the Trust had been working to clear the backlog and reduce the waiting time but that it still stood at 12 months;
2. The evidence given to the Inquest was that after falling Mrs Davies needed an ambulance urgently - a Category 2 response. The Inquest heard that the wait for the ambulance was very distressing and arrived outside the target times due to ambulance availability in Greater Manchester at that time. The Inquest heard evidence that there was an ongoing issue of ambulance availability.