Judith Marsland · Prevention of Future Deaths report

On the 4ᵗʰ November 2025, I commenced an investigation into the death of Judith Marsland. The investigation culminated in an inquest on the 9ᵗʰ June 2026. At the inquest, I found that Mrs. Marsland’s medical cause of death was -

1a) Urosepsis and congestive cardiac failure
1b) Ischaemic heart disease
1c) Severe coronary arterial atherosclerosis

II Chronic kidney disease stage 3, hypertension, chronic obstructive pulmonary disease.

On the 9ᵗʰ June, I returned a narrative conclusion at the inquest which found that Mrs. Marsland died at Tameside Hospital on the 14ᵗʰ November 2025 from the complication of sepsis, which developed from a urinary tract infection which had likely been present since at least the 6ᵗʰ November 2025, and having been discharged from the hospital on the 7ᵗʰ November during which time an infection was not identified or treated.

Mrs. Marsland had a medical history which included heart failure and chronic kidney disease. In the 12 months prior to her death, she was treated for multiple urinary infections. It is likely that on or around the 6ᵗʰ November 2025 she was suffering from a urinary infection. On the 7ᵗʰ November Mrs. Marsland attended A&E at Tameside General Hospital and reported worsening intermittent bleeding and abdominal pain.

In the emergency department sepsis was considered but she was not managed on a sepsis pathway. Mrs. Marsland was transferred to the gynaecology hub for further review. Blood results that indicated acidosis and elevated inflammatory markers were not reviewed and acted upon by the gynaecology clinical team. As a result, Mrs. Marsland was discharged from hospital and was not prescribed antibiotics.

On the 12ᵗʰ November, Mrs. Marsland attended A&E with an increase of pain. Clinical assessment identified septic shock with multiorgan failure, and she was commenced on antibiotics. Her condition deteriorated and Mrs. Marsland died in hospital on the 14ᵗʰ November 2025.

3) I heard evidence from ████████, the lead investigator from the Trust PSII that Mrs. Marsland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7ᵗʰ November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home.

4) ████████ evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians.