Hospital death prompts coroner's concerns

Joanne Stones died in Scarborough Hospital in September 2023

A coroner has expressed concerns about delays in hospital treatment, including a failure to recognise medical alert bracelets before a woman's death.

Joanne Stones, 53, died at Scarborough Hospital on 17 September 2023 and following an inquest last month the area's assistant coroner has issued a Prevention of Future Deaths report.

Gillian Kane said Ms Stones had complex medical problems and she found during the course of the inquest there were "delays in recognising and appropriately treating" her condition.

The York and Scarborough Teaching Hospitals NHS Foundation Trust said it recognised the coroner's concerns and would set out an action plan to address any recommendations.

Ms Kane said Ms Stones' medical conditions included Antiphospholipid syndrome (APS) and in 2021 she had suffered Catastrophic Antiphospholipid Syndrome (CAPS) which led to Addison's Disease (AD).

As a result her body could not produce cortisol and she required lifelong steroid treatment with hydrocortisone. If she had an infection she would need her hydrocortisone level to be recalibrated to manage it.

Ms Kane said Ms Stones had been taken to hospital on 10 September 2023 where she was given a provisional diagnosis of suspected gallstones and discharged home with oral antibiotics and analgesia.

Her medical notes showed that those treating her were aware that her medical history included the diagnoses of APS and AD.

Three days later she attended the hospital for a planned ultrasound and was diagnosed with Acute Cholecystitis with gallstones.

She was again discharged home and advised to complete the course of antibiotics she had previously been given.

However, on the 16 September she was blue lighted to hospital with suspected Cholecystitis.

'Failure to prioritise'

The ambulance service had alerted the hospital about her condition but when she arrived there was a delay of two hours before she was moved to resus.

The coroner added there had also been a delay in administering intravenous antibiotics and fluids leading to Ms Stones developing hypoglycaemia.

There was also a substantial delay before it was recognised that she had AD and required steroids.

Ms Stones died in intensive care on 17 September 2023.

Ms Kane said she was unable to determine on the balance of probabilities if the delays in treatment "caused or more than minimally contributed to her death".

"However, there was evidence of omissions and delays in the treatment that Joanne received which caused me concern," she added.

The coroner raised a number of concerns in her report.

The failure to prioritise her despite the ambulance service alert, that Ms Stones had worn two medical alert bracelets about her existing conditions which staff did not observe.

There were also no red flags on her medical records highlighting her APS and AD diagnoses to the treating team.

Ms Kane said doctors had to rely on a "very sick patient" to confirm any medical conditions.

"There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions," she added.

"It was not clear from the medical notes that staff treating Joanne had considered the relevance of her APS and AD in her treatment plan."

'Ensure learning'

A spokesperson for York and Scarborough Teaching Hospitals NHS Foundation Trust said it wished "to extend our sincere condolences to Ms Stones' family".

"We recognise and share the concerns raised by HM's Coroner. Following the conclusion of the inquest, we acknowledge the coroner's recommendations and fully accept the need for further action.

"We will be setting out our action plan and implementation timetable to meet the coroner's deadline, and a full response will be shared with the coroner in due course.

"We remain fully committed to patient safety and will take all necessary steps to ensure learning and improvement where needed."

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