Margaret Anne Ferry · Prevention of Future Deaths report

On 14th May 2015 I commenced an investigation into the death of Margaret Anne Ferry, aged 66. The investigation concluded at the end of the Inquest on 20th October 2015.

The conclusion of the Inquest was that Margaret died as a result of the progression of a naturally occurring disease process but opportunities to ameliorate that process were lost as a consequence of a lack of communication.

The medical cause of death was: -
1a Bronchopneumonia
1b Necrotising Fasciitis
and
II Diabetes Mellitus; Raised Body Mass Index

Margaret had a number of underlying health issues and was admitted to Sunderland Royal Hospital on 8th January 2015. She underwent a planned amputation of her left 5th toe on 11th January. Thereafter she developed a deterioration to her skin integrity particularly around her abdomen and thighs. On 6th March a referral was made to the plastic surgery team at University Hospital of North Durham. Their role was to provide advice to the treating doctors in Sunderland.

There was no clear understanding in each hospital of the role of the other in Margaret’s care. There was no clear understanding of the different practices and procedures in each hospital and the impact this would have on Margaret. There was inadequate communication, both written and oral, between the various doctors involved in Margaret’s care. Although Margaret was seen by a number of health professionals, including doctors, there was a lack of leadership, meaning that there was no cohesive treatment plan.

On 22nd April 2015 Margaret underwent a debridement procedure which, although in itself successful, the missed earlier opportunities meant that Margaret’s underlying health problems had been exacerbated and she died on 12th May 2015.

1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred.
2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures.