Coroner concerned staffing levels on 'under pressure' hospital ward led to death

Yahoo

4 hours ago

A CORONER has urged a Cumbrian NHS Trust to take action after it emerged that an 'understaffed and under pressure' hospital ward may have been a factor in a woman's death.
Sarah Kathleen Hill, 78, from Dalston, died in the Cumberland Infirmary on November 8, 2024, after undergoing an elective procedure to remove gallstones.
Mrs Hill underwent the procedure, an endoscopic retrograde cholangiopancreatography (ERCP) on November 5.
The procedure was partially successful, though the largest stone remained, and the procedure 'abandoned', according to coroner, Margaret Taylor.
Ms Taylor sent a Prevention of Future Deaths report to the North Cumberland Integrated Care NHS Trust (NCIC) with concerns relating to the care of Mrs Hill after the procedure, during which her condition deteriorated, leading to her death.
Ms Taylor wrote that Mrs Hill complained of 'nausea, vomiting and pain' post-operatively, and she was subjected to a CT scan to rule out pathological issues.
The CT showed no evidence of perforation, but Mrs Hill was admitted for pancreatitis, a 'recognised complication of ERCP'.
On November 6, her condition worsened, and on November 7, Mrs Hill collapsed while going to the toilet.
A further CT scan on November 7 showed 'significant worsening' of her pancreatitis and other complications.
The surgical team decided Mrs Hill was 'not for escalation', and at 5pm, she had an unwitnessed fall 'at a time she was meant to be closely observed'.
Mrs Hill became unresponsive shortly afterwards, going into cardiac arrest, and blood results showed she had developed multi organ failure.
Mrs Hill died in the early hours of November 8.
Ms Taylor wrote to NCIC requesting action to be taken in relation to five areas of concern during this period.
She stated: "There was a lack of evidence that suggested appropriate falls risk assessments had been undertaken and a failure to report falls/collapses on the ward
"There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach .
"There was a lack of frequent recorded observations necessitated by Mrs Hill's deteriorating condition.
"Mrs Hill was placed in a side room where she was not easily observed without consideration given for the need for additional monitoring which led to her being left alone for extended periods of time.
"I was advised that the ward was understaffed and under pressure."
"I was told that despite this being appropriately escalated, nurses were caring for ten patients when the expected allocation would be six patients for each nurse on duty .
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"No further help was provided to the ward following escalation.
"The evidence presented to me was that this was not an unusual situation on the ward."
NCIC is obliged to respond to the concerns raised by July 22, 2025.
A spokesperson for NCIC said: "We would like to express our heartfelt condolences to the family and loved ones of Mrs Hill.
"We fully accept the findings from the coroner and have implemented the learning points raised in the report."