Daphne Gillian AUSTIN · Prevention of Future Deaths report

On 22 June 2023 I commenced an investigation into the death of Daphne Gillian AUSTIN. The investigation concluded at the end of the inquest on 8th August 2024. The conclusion of the inquest was a narrative.

I found that the medical cause of death was:

1a Urosepsis and Acute Kidney Injury

1b

1c

II Right cerebral Infarct

Ms Austin was 71 years old. She suffered from diabetes. On 22nd May 2023 Ms Austin was admitted to the Cumberland Infirmary, Carlisle. She had had a stroke. Whilst in hospital, Ms Austin's glucose levels were poorly controlled. She also became dehydrated. Ms Austin's fluid balance was not monitored in an effective manner. On 14th June 2023 it became apparent that Ms Austin had sustained an acute kidney injury. Blood testing was not carried out on 15th or 16th June, it is more likely than not that this was because of industrial action by junior doctors. On 17th June 2023, Ms Austin's condition deteriorated and it became apparent that she had developed sepsis. Despite treatment, Ms Austin died as a result of that condition on 18th June 2023.

Neglect (being the ineffective monitoring of Ms Austin's fluid balance and the fact that blood testing was not carried out on 15th or 16th June 2023) contributed to Ms Austin's death.

(1) I received evidence of the planning that had gone into preparing the trust for strikes. However, there was evidence from one of the Trust's consultants that on the day of the strike she had to "look after nearly 25 patients" and that "due to the junior doctor’s strike on 14/06/2023, Mrs Austin did not receive any medical input that day". Another consultant gave evidence that despite being listed as one of the consultants covering the unit (in the contingency planning evidence) he was probably dealing with other duties on that day. In the circumstances I am concerned that the planning that seeks to ensure safe levels of cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths.