Coroner's concerns over death at Stevenage's Lister Hospital
- Credit: Archant
A patient's death at Stevenage's Lister Hospital, after "his care was not escalated in a timely fashion", has prompted Hertfordshire's senior coroner to call for action to prevent future deaths.
A 60-year-old Welwyn Garden City man, who this paper is not naming, died of respiratory failure on January 5, 2020, an inquest found.
He had been admitted to Lister on November 21, 2019, following a fall and injury to his spine.
With a background of severe kyphoscoliosis - a spine curvature that reduces lung capacity - and chronic obstructive pulmonary disease, he was on long-term home oxygen and used a ventilator at night.
He was discharged to Welwyn's Queen Victoria Memorial Hospital on December 21 for rehabilitation, but readmitted to Lister on January 3, drowsy and in respiratory failure.
No Respiratory Support Unit bed was available. He was transferred to a ward close to the RSU on January 5, but was dead on arrival.
During this January's inquest, Herts senior coroner Geoffrey Sullivan heard medical witnesses' evidence which he said identified "failings in patient care".
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"Despite being significantly unwell on his return to Lister, his care was not escalated in a timely fashion," he said.
Mr Sullivan said consultant review only took place 24 hours after admission, despite "a full complement of staff".
Evidence suggests NEWS - a National Early Warning Score to improve detection and response to patients' deterioration - was not calculated or recorded accurately, despite being "a fundamental aspect of patient care", he said.
He concluded: "It is not clear whether these matters contributed to his death", but "they present a wider concern for the provision of future care".
In a notice to the East and North Herts NHS Trust, which runs Lister, Mr Sullivan writes: "In my opinion, there is a risk future deaths will occur unless action is taken."
A spokesman said: “First and foremost we would like to offer our sincere condolences to [the patient's] family and friends.
“Following [his] death, we conducted a full investigation and have made a number of changes to prevent cases like this from happening again.
“We are cooperating fully with the relevant authorities as we respond to the notice.”