Mrs Mary (also known as Moira) Forlin · Prevention of Future Deaths report

Mrs Mary (also known as Moira) Forlin died in the Royal Sussex County Hospital, Brighton, on 28th July 2024. Her death was referred to the Coroners Service on 8th August 2024. There was then a lengthy and detailed investigation as to whether her death should proceed to inquest. The inquest was eventually opened on 24th July 2025. The inquest was heard, including live evidence from a Geriatric Consultant, on 9th December 2025.

Further time was then afforded to the Interested Persons to provide legal submissions as to whether the duty to issue a Prevention of Future Deaths report under Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 arose. Regrettably, there was an internal administrative delay within that latter timescale such that this report is only now being issued, following receipt and consideration of submissions from the family and Trust.

Mrs Forlin was admitted to hospital as an emergency on 21st July 2024 following a fall at home with a long lie. She was suffering from respiratory failure, likely driven by an infection. The source was never identified and antibiotic treatment did not resolve this over an extended period. Microbiological analysis was not undertaken. Fluids were administered and attempts made to balance organ support, with occasional low level overload. She remained at high risk throughout admission. At around 1030 on 27th July Mrs Forlin suffered a sudden collapse with lowering of oxygen and blood pressure and increased heart rate. The immediate medical cause of the collapse could not be identified, but despite emergency treatment she remained unresponsive. Treatment continued until it was agreed to no longer be in her best interests. She sadly died the following morning from multiorgan failure arising from infection of unknown source and respiratory failure.

I recognise and acknowledge the actions taken by the Trust with regard to the timeframe and speed with which an unidentified infection may be addressed by antibiotic medication.

Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.

Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.

Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working.

I am acutely aware that where action has been taken, a ‘PFD’ report may be otiose, but in this case my concern persists, notwithstanding the action taken, and nor do I consider that resource grounds significantly preclude further action. I also consider, given the obvious and welcome development of the Electronic Patient Record, that there remains a realistic prospect of some action being taken by which that system flags up, alerts and or far more proactively drives clinical assessment and review, where infection markers persist.

I duly consider there remains a risk of further deaths, and that further action should be taken to reduce the risk of death in such circumstances, fully accepting that it is not possible to eliminate that risk entirely.