MARY MARGARET WHITLOCK · Prevention of Future Deaths report

On 1 September 2023 I commenced an investigation into the death of MARY MARGARET WHITLOCK, AGE 84. The investigation concluded at the end of the inquest on 17 December 2024. The conclusion of the inquest was la Aspiration of food contents lb Fracture of Cervical Vertebra and Dementia

Accident contributed to by neglect

Mary Whitlock died at Broomfield Hospital on 23 August 2023. Mrs Whitlock sustained a fracture of her cervical vertebra when she tripped at her care home and struck her head against the wall on 21 August 2023. Mrs Whitlock was conveyed to hospital with neck pain. CT scan of her head revealed no bleed or infarct and Mrs Whitlock returned home that night; no imaging was completed of the neck. Mrs Whitlock was in pain and could not swallow paracetamol the next morning and was readmitted to Broomfield Hospital where further scans revealed cervical fractures at C1 and C2. Advice was that she was not suitable for surgical intervention and was for conservative treatment with a collar that was difficult to tolerate. Broomfield Hospital did not provide the collar clinically recommended until 23 August 2023. Swallowing problems were a known risk for Mrs Whitlock’s injury and there was no plan for managing oral intake. Concerns about swallowing tablets and oral administration of analgesia were noted in the medical records overnight and not handed over to the day shift or reviewed in the ward round. Mrs Whitlock suffered aspiration following assisted feeding of

her lunch on 23 August that was treated with suctioning and oxygen with improvement in her condition. Mrs Whitlock was required to be nil by mouth, undergo chest x-ray, a Speech and Language Team assessment, antibiotics and intravenous fluids. This information was not shared with all the ward staff due to staff shortages. Mrs Whitlock was fed some of her remaining lunch and suffered shortness of breath and oxygen desaturation that required a emergency medical call at approximately 13:00 hours and Mary was place on end-of-life care and died. Mrs Whitlock sustained a Fractured Cervical Vertebrae with Dementia that put her at risk of aspiration, and she was fed when experiencing swallowing difficulties.

(1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this did not cause or contribute to this death this matter was not part of the Trust review, and no safeguards was raised.

(2) Evidence of clinical witnesses is that Notley Ward was (at the time of this death) and remains understaffed despite escalation within Trust

(3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury