MISSED OPPORTUNITIES LED TO UNTIMELY DEATH

[ TRACEY ANN SOUTH was 51 years of age at the time of her death. Having suffered with spina bifida, she spent her life in a wheelchair. On 22 March last year she was admitted to King’s Mill Hospital in Nottingham following her carer’s concerns that she seemed weaker than normal and had fallen out of her chair.

She remained on Ward 34 until 26 April when she was transferred to an ‘outlier’ ward due to bed pressures, before being discharged home on 3 May 2022. At the time of her discharge Tracey had not been seen or reviewed by a doctor for five days.

The following day, 4 May 2022, Tracey was an emergency readmission back to King’s Mill Hospital and by the time she was properly reviewed she was deemed to be too unwell to be rescued. In short, Tracey was beyond medical help at that juncture. She tragically died on 9 May 2022, at King’s Mill Hospital, having been placed on an end-oflife pathway.

At an inquest on 19 April this year at Nottingham Coroner’s Court the coroner delivered a narrative verdict citing numerous missed opportunities by medical staff between 27 April 2022 and 5 May 2022, leading to a failure to rescue the patient who would likely have lived longer had she received appropriate treatment.

In a statement, Rotheras Solicitors, who represented Tracey’s family, said: “It appears clear that there were a number of missed opportunities and failings by medical staff, which meant that they did not rescue Tracey. They had not recognised the key issues requiring urgent treatment and delayed in providing her with fluid resuscitation and other medication in good time.

“Despite her kidney injury, the acute kidney injury treatment bundle was not provided to her in a timely manner and there were a number of service delivery problems, including a failure to repeat bicarbonate levels, to repeat blood tests, a lack of consultant review and no highlighting of outstanding jobs at the times of transfer, which meant potentially lifesaving treatment was overlooked or delayed.

“Communication was also lacking and infrequent, both between staff and with

Tracey’s family, who were desperate for news of her health in a COVID era where visiting the ward was not routinely permitted.

“While her family note the recommendations made by King’s Mill Hospital following their own investigation into Tracey’s untimely death, they are keen that these lessons must be learnt, and her death must not be in vain. Acute kidney injury is a medical emergency and must be treated as such. Tracey’s family hope that the findings at inquest help to safeguard other vulnerable patients in the future.”

Julie Walker of Rotheras Solicitors said:

“Tracey’s family have shown great strength since her death. It has been a lengthy and difficult process for them. I am pleased that the coroner recognised that there were missed opportunities by King’s Mill, and I hope that lessons are now learnt.

“Ensuring that questions were answered at the inquest, and responsibility was taken, was the last thing which the family could properly do for Tracey. I hope that they now feel they have some of the justice which they deserve for her.” q