Hull coroner raises concerns over patient's death

Sally Robinson, who is the assistant coroner for East Riding and Hull, has written a prevention of future deaths report raising concerns over Linda Heath's treatment

A coroner has raised concerns following the death of a woman at Hull Royal Infirmary.

Linda Heath, 76, died in March 2022 from sepsis after a sore became infected, an inquest found.

East Riding and Hull assistant coroner Sally Robinson has written a prevention of future deaths report highlighting issues with her treatment.

The reports are sent to the authorities when a coroner thinks action is needed to protect lives.

In her report, Ms Robinson said Mrs Heath was first discharged from hospital with a pressure sore on 11 February 2022.

The coroner said that the hospital's Immediate Discharge Summary (IDS) note "did not mention that a district nurse referral was required nor was a referral made by the hospital".

The coroner noted: "The nursing summary on 10 February stated that the care would be transferred to the district nursing team to include dressing selection and equipment required at home.

"This did not get added to the IDS."

Mrs Heath telephoned her GP on 3 March saying her condition had worsened. Her doctor made a home visit the next day and arranged her transfer to Hull Royal Infirmary.

Despite surgery, she died on 31 March.

Mrs Heath died at Hull Royal Infirmary on 31 March from sepsis, a coroner's inquest found

Ms Robinson said she had concerns that her hospital discharge note "did not include relevant or sufficient information about treatment in the community needs or a nursing summary".

She added there was an "over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers".

The report said: "Despite the presence of a difficult sacral sore, which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery."

She also wrote that "no trigger appears to exist whereby GPs conduct follow-up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen".

A spokesperson for Hull University Teaching Hospitals NHS Trust said: "We would like to extend our condolences to the family of Mrs Heath.

"We always try to learn where processes could be improved and will be responding to the coroner in due course."

Mrs Heath's GP, the St Andrews Surgery on Hessle Road, said it "would like to extend our heartfelt condolences to the family of Ms Heath".

"In light of the report, we have thoroughly reviewed and enhanced our procedures and processes, which now incorporate more robust procedures and training," the practice said.

"We want to reassure all patients of St Andrews that we remain committed to delivering the highest quality of care."