Judith Hughes · Prevention of Future Deaths report

On 16 October 2020 I commenced an investigation into the death of Judith Claire HUGES aged 86. The investigation concluded at the end of the inquest on 05 November 2025. The conclusion of the inquest was that:

Judith died from natural causes.

Judith Hughes had a past medical history of significant heart disease. She was admitted to Peterborough City Hospital on 30 July 2020 following a tonic clonic seizure, where it was also identified that she was suffering from fast ventricular atrial fibrillation and a high heart rate. These issues were treated and Judith was discharged home on 30 July 2020 at which point there was no evidence that she was in cardiac failure. Judith's cardiac function declined from this point and she was further admitted to Peterborough City Hospital on 10 August 2020 when there was clear evidence of worsening heart failure. Sadly despite ongoing monitoring and care both in hospital and in the community Judith died at home, 129 Park Road in Peterborough, at 0030 hours on 07 October 2020.

The Inquest heard evidence about the Trust's use of the 'Close Observation Risk Assessment' (p1903 Medical Records Bundle). This requires scores to be attributed to several factors including 'inpatient falls during this admission' and 'previous falls'. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death.