Mrs Kathleen Booth · Prevention of Future Deaths report

On the 7ᵗʰ July 2023, I commenced an investigation into the death of Mrs Kathleen Booth. The investigation concluded at the end of the inquest on 24 October 2023. The conclusion of the inquest was a narrative conclusion of complications following a fall. The cause of death was:

1a) Stroke
1b) Fractured neck of femur
1c) Low blood pressure
II) 4 day delay in operating on the fractured neck of femur

Mrs Booth had been admitted to hospital as an emergency following a fall in her own garden on 09 June 2023. She was transported by ambulance to the Royal Stoke University Hospital, Stoke-on-Trent. A hip x-ray confirmed displaced intra-capsular neck of femur fracture on the left. On Monday 12 June 2023, a decision was made to operate. The operation was due on the 12 June 2023 but was delayed until the following day due to a large amount of trauma patients in the hospital. On 13 June 2023, the surgery was performed and was uneventful. After surgery Mrs Booth was found to be alert and comfortable in the recovery area. Around 9pm, she suffered a sudden deterioration and passed away.

1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time. Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available.

2. Earlier intervention is associated with better outcomes.

3. Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover over the weekend is limited.