Ailsa Stewart · Prevention of Future Deaths report

On 3rd December 2019, Christopher Briggs, Assistant Coroner, opened an inquest into the death of Ailsa Stewart who died on 1st May 2019 aged 62 years. The investigation concluded at the end of the inquest which I heard between 6th and 9th April 2021.
A post mortem examination undertaken by Dr ████████, Consultant Pathologist on the Home Office Register, determined that Ms Stewart died as a consequence of:
1.a) Sepsis; due to
1.b) Pneumonia, pyelonephritis, limb ischaemia, pressure ulcers and epithelial damage due to prolonged contact with urine.
2) Obesity, Type II Diabetes.
By way of conclusion, I recorded that Ms Stewart died as a consequence of natural causes, contributed to by neglect.

Ms Stewart was bed-bound as a consequence of obesity, and suffered with Type II diabetes. She lived alone and was essentially dependant on domiciliary carers for all care.
On 16th April 2019, carers asked a GP to visit Ms Stewart as they were concerned she was unwell. Following an examination, the GP sent Ms Stewart to hospital for further assessment and possible treatment. As a consequence, Ms Stewart’s care provider suspended her package having assumed she would be admitted to hospital without verifying this was the case.
Ms Stewart was assessed in the Emergency Department and following tests, was not considered to be acutely unwell. On the Morning of 17th April 2019, she was deemed medically fit to return home and transport was arranged via the ambulance service on the basis that her care package remained in place. An ambulance crew left Ms Stewart in bed at her home on that day, understanding that carers would be arriving to attend to her shortly.
On 29th April 2019, the same ambulance crew returned to Ms Stewart’s home to transport her to a pre-arranged medical appointment whereupon they found her to be gravely ill in her bed. She was taken to hospital where she subsequently died.
Because her care package had been suspended, Ms Stewart received no domiciliary care between 17th and 29th April 2019. This lack of care caused her death.

The court heard evidence as to an extensive range of actions which local agencies have taken in response to Ms Stewart’s death to try and reduce the risk of a similar set of circumstances occurring again. That said, it was clear from the evidence that in England, family members play an essential part in ensuring continuity of care is maintained by sharing information between different agencies, and facilitating the co-ordination of care provided to vulnerable patients, particularly in circumstances where unplanned hospital attendances are required.
It is a matter of concern that no cohesive national framework or guidance exists across health and social care, to prescribe the circumstances in which a domiciliary care package can be suspended, or sets out specific rules as to the roles and responsibilities of particular agencies to convey information when a vulnerable patient is sent home from an urgent care setting without having formally been admitted.