Mrs Maureen Christy · Prevention of Future Deaths report

Conclusion of Investigation (Section 4)

Narrative Conclusion.
On 26th November 2020, Mrs Maureen Christy fell in the hallway of her home at 12 Toronto Avenue, Fleetwood, Lancashire, FY7 8HB. The cause of her fall was muscle wasting and consequential poor balance which was a natural expression of her frailty. Mrs Christy was transferred to Blackpool Victoria Hospital, and presented at the Accident and Emergency Department at 13.19 hours on the same date. An intrapsular fracture of the neck of the left femur was confirmed on plain x-rays. On 27th November 2020, Mrs Christy underwent a hemiarthroplasty under spinal analgesia. In the course of her admission, Mrs Christy presented with delirium, the causes of which were multifactorial. The delirium, low weight and cognitive impairment would have made Mrs Christy more vulnerable to Covid-19 and would have affected her ability to cope with it. On 8th December 2020 and/or shortly prior thereto, Mrs Christy was exposed to, and contracted, the SARS-Cov-2 virus on Bay 2 of Ward 35 of the Hospital, on which she was resident at the time. In consequence of the known exposure, she was identified as a “Covid contact” within the meaning of the Hospital’s internal guidance but was not tested for Covid-19 under the Hospital’s internal guidance at that time. The absence of such further testing in the Hospital did not contribute to Mrs Christy contracting the SARS-CoV-2 virus, or to her death. Mrs Christy was discharged home on 11th December 2020 and developed symptomatic Covid-19 on or around 14th to 16th December 2020, by reason of having been exposed to the SARS-CoV-2 virus in Bay 2 of Ward 35 of the Hospital, the Covid-19 being hospital-acquired. Mrs Christy’s presentation deteriorated and, on 4th January 2025 she died at home. Her death was verified at 00:15 hours on 5th January 2021. Frailty of old age had increased Mrs Christy’s vulnerability and was contributory to her death.

Cause of death:

1a Hospital-acquired Covid-19 infection
b Hip fracture (operated)
c
II Frailty of old age

Box 3 of the Record of Inquest recorded as follows:

See Box 4.

(1) The central policy or practice change with which this inquest was concerned was that pertaining to the testing of those designated as “Covid contacts”.
(2) The adoption and understanding of good policy and practice, serves to protect patients and to provide clinicians with an overarching framework within which to work. It provides clinicians with the security of knowing what is expected of them in their clinical practice.
(3) The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest.
(4) Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care.