Eleanor Smith Deceased · Prevention of Future Deaths report

On 28 September 2023 I commenced an investigation into the death of Eleanor Smith Deceased. The investigation concluded at the end of the inquest on 11 April 2024. The conclusion of the inquest was a narrative conclusion: Died due to an infection the source of which could not be ascertained together with the physiological stress of a surgical procedure contributed to by underlying natural disease and an injury sustained in an accidental fall. It is not possible to say to what extent antibiotics were effectively administered or whether the delay affected the outcome.

The cause of death was:

1a. Infection of unknown aetiology

1b Frailty of old age

II Left ventricular systolic dysfunction, Atrial fibrillation, Left neck of femur fracture.

On 17 September 2023 within Crossway, 1 Swinhoe Road, Beadnell Eleanor Smith suffered an unwitnessed fall using her walker when she stumbled and fell against the doorpost of the bathroom door. She was conveyed to Northumbria Specialist Emergency Care Hospital where an x-ray identified she had sustained a fracture to the left neck of femur. No infection was identified on admission. She was too unwell to undergo surgery initially and underwent surgical repair of the fracture with insertion of a left dynamic hip screw without complication on 19 September 2023. Postoperatively she developed an infection with a rising white cell count and CRP. There was a significant delay in the administration of intravenous antibiotics which were first administered at 18.00 hours on 23 September 2023 although it is not possible to say to what extent antibiotics were effectively administered or whether the delay affected the outcome.

Investigations undertaken were unable to identify the source of the infection and despite treatment she continued to deteriorate and died within Northumbria Specialist Emergency Care Hospital on 24 September 2023.

1. It was the concern of the family throughout the investigation that there was a delay in the administration of IV antibiotics and the antibiotics were not administered effectively. The Trust accepted that there was a significant delay in the administration of antibiotics of a period of 24 hours but that it was unlikely that the delay affected the outcome. The family gave evidence that they were present until around 21.00 hours on 23 September 2023 and described difficulties experienced by staff on 23 September 2023 in the siting of a canula. There was an attempt for the canula to be placed in one arm, then the other and was eventually sited in the foot. It was the position of Trust that from 17.56 hours on 23 September 2023 there was a working cannula and prescribed medication was administered. I accepted the evidence of the family and I am concerned that the medical records did not accurately record the events and siting of the canula. I am further concerned as to whether prescribed medication on this occasion being antibiotics were effectively administered and what checks there are to ensure the effective administration of medicines.