Julie MORREY · Prevention of Future Deaths report

On 24th January 2019 I commenced an investigation into the death of Julie MORREY aged 58. The investigation concluded at the end of the inquest on 22nd October 2019. The conclusion of the inquest was that Julie MORREY died as a result of ‘Natural causes contributed to by neglect’ and the medical cause of her death was:-
1a Acute renal failure complicating chronic renal failure post renal transplant for focal segmental glomerulosclerosis/acute tubular necrosis and glomerulonephritis with small thrombiosed right kidney.
1b Bronchopneumonia.
1c Chronic obstructive pulmonary disease and multifactorial immunosuppression.
II Ischaemic heart disease, lack of fluids.

The deceased passed away in the Royal Stoke University Hospital, Stoke-on-Trent on 10th January 2019 having admitted herself there on 7th January 2019. She had a number of pre-existing medical conditions, the most significant of which was a transplanted kidney which she had had since 2016. Believing that she was suffering with a chest infection, she visited her GP on 4th January 2019 but self-presented to Accident and Emergency on 7th January 2019 where she was recognised as suffering from renal failure and bronchopneumonia. Despite timely review by a renal specialist, she was not provided with adequate fluids for over 24 hours by which time her condition had worsened and despite admission to the ICU she deteriorated and died.

1. There was a clear lack of communication between the hospital departments as to which department was responsible for the patient after she was assessed by a renal specialist and a plan made for her care and whilst she awaited a bed on the Renal Unit during which time she was looked after on the AMU. During this time she was without fluids for over 24 hours.

2. There was a clear failure by nursing staff to pro-actively manage her condition due to a lack of policy, procedure and professional responsibility to the patient.

3. There was no review of the patient by a senior clinician for 24 hours following her admission and whilst she awaited a bed on the Renal Unit.