Failings at hospitals contributed to woman's death

Pamela Hall died on 5 November 2023 after being admitted to Highbury Hospital three days earlier

A woman died after a series of failures across two hospitals, an inquest has found.

Pamela Hall was admitted to Highbury Hospital in Nottingham on 2 November 2023 after being sectioned, following a stay at Nottingham City Hospital since 18 October of that year.

Nottingham Coroner's Court heard the 70-year-old weighed about 26kg (4st 1lb) when she died on 5 November.

The inquest was told of a string of failures by the trust that runs Highbury Hospital - and a number of staff suspensions over the case - and on Wednesday, the jury said Ms Hall would have survived for longer had she received the right care.

'Falsely indicated' observations

At the inquest, Nottinghamshire Healthcare NHS Foundation Trust - which runs Highbury, a mental health hospital - admitted multiple failings.

These included "inappropriate management" at Highbury Hospital's Cherry ward of pressure sores, a failure to monitor food and fluid charts, and noting that 10-minute observations were not "consistently completed".

"At times, ward staff falsely indicated an observation had been completed when it had not," the trust said.

During the inquest, which began hearing evidence on 18 August, the trust said "a number of staff" were suspended after it carried out an investigation.

Although the above failings had not more than minimally contributed to Ms Hall's death, the jury found that others did, including a failure to seek guidance from Nottingham City Hospital when she was transferred, a failure to take blood tests on arrival at Highbury, and not establishing a care plan for Ms Hall while there.

The inquest jury also found Ms Hall was not physically well enough to have been discharged from City Hospital to Highbury.

It added there was "a failure to carry out blood tests" at City Hospital on 2 November, which it said on the balance of probabilities "would have indicated a decline" in her condition since she was deemed fit for discharge three days earlier.

"Pamela should not have been transferred to Cherry ward," the jury said. "She was neither fit for discharge, nor was Cherry ward a fit place for her to be discharged to."

It also found Ms Hall "would have survived for longer than she did", had she been moved back to an acute hospital once she had arrived at Highbury.

Delivering its conclusions, the jury said: "Pamela died as a result of natural causes, and failures in both City and Highbury hospitals."

An inquest was held over seven days at Nottingham Coroner's Court

Ms Hall was born in Crewe but grew up in Dudley.

The court heard she had a history of severe depression and was well-known to local mental health services.

On 21 August 2017, her husband Steve was killed and she survived when the pair tried to take their own lives on rail tracks in Cheshire.

Ms Hall – who was believed to be in a suicide pact with her husband - survived after having a leg amputated below the knee, the inquest heard.

After frequent spells at a mental health hospital in Dudley, she was discharged on 2 August 2023 and moved to Aslockton Hall Nursing and Residential Home in Nottinghamshire to be nearer her sister.

Her weight at the time of arrival was listed as about 32kg.

Staff at the home, the inquest heard, became increasingly worried as Ms Hall was rarely eating or drinking, and sometimes did not accept her medication, and after escalating their concerns, she was eventually admitted to the Queen's Medical Centre in the early hours of 17 October.

'Emaciated' appearance

She was transferred to Nottingham City Hospital - another site run by Nottingham University Hospitals (NUH) NHS Trust - the following day, where the inquest heard she began to gradually eat food and take fluids alongside her medication.

On 30 October, she was deemed medically fit for discharge by staff, and on 2 November she was taken to Highbury Hospital.

Staff described being concerned as to her "emaciated" appearance, but no blood tests were taken and she was not weighed on arrival.

She was placed in a room on the Cherry ward, where concerns about her care escalated, but she died at 17:20 on 5 November after her condition deteriorated.

A pathologist gave a medical cause of death as bowel ischaemia - a condition that occurs when blood flow to the bowel is blocked.

The jury found other factors that contributed to her death were dehydration, severe depression, acute kidney injury and frailty.

Despite the multiple failings, coroner Simon Burge declined to issue a prevention of future deaths report over the case, and noted that he was "impressed" by the changes that had been made since Ms Hall's death.

"On this occasion, I don't consider that there are concerns which would need to be addressed [by a report]," he said.

Ms Hall was taken to the Queen's Medical Centre in Nottingham on 17 October

Following the inquest, Nottinghamshire Healthcare chief executive Ifti Majid "unreservedly" apologised to Ms Hall's family.

"We identified a number of aspects of Pamela's care which were not of the standard they should have been," he said.

"Since 2023, we have undertaken a comprehensive and sustained programme of improvement in our mental health services for older people."

Tracy Pilcher, chief nurse at NUH, added: "We would like to offer our deepest condolences to the family of Pamela Hall at this very difficult time.

"We accept the findings given by the jury and will work with colleagues to consider the feedback and implement changes to help make improvements for the future."

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