Coroner's concerns over Cumberland Infirmary staff shortages
A coroner has raised concerns that a woman's death in hospital may be linked to an "understaffed and under pressure" ward.Assistant coroner for Cumbria Margaret Taylor issued a prevention of future deaths report to the trust which runs the Cumberland Infirmary in Carlisle, following the death of a patient.The document urges the North Cumbria Integrated Care NHS Foundation Trust (NCIC) to take action after it emerged nurses were looking after 10 patients each instead of the expected six on the day Sarah Kathleen Hill died.The trust said it "fully accepted" the coroner's findings and had implemented "learning points" raised in the report.
The report said Mrs Hill, 78, had been admitted to hospital last November with gallstones, but a procedure to remove them only partly worked.She became increasingly unwell in the following days and collapsed while going to the toilet.The same day she had an unwitnessed fall "at a time when she was meant to be closely observed", Ms Taylor said in her report.Mrs Hill became unresponsive and died the day after the fall.
'Understaffing not unusual'
An inquest into her death held last month concluded she died as a result of "recognised complications of a necessary medical procedure".Ms Taylor said the evidence heard "revealed matters giving rise to concern about the standard of nursing care" that Mrs Hill received.She raised concerns about the patient being left alone in a side room where she could not easily be checked on, adding there was a lack of evidence to suggest a falls risk assessment had been undertaken and a lack of frequent recorded observations warranted by Mrs Hill's condition.Ms Taylor added: "I was advised that the ward was understaffed and under pressure."She said although understaffing had been flagged, no help arrived on the ward."The evidence presented to me was that this was not an unusual situation on the ward," she said.A spokesman for NCIC offered their condolences to Mrs Hill's family."We fully accept the findings from the coroner and have implemented the learning points raised in the report," they added.The trust must respond to the coroner's concerns by 22 July, detailing which actions it intends to take to address them.
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