David Scott: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 26/05/2024

Ref: 2024-0284

Deceased name: David Scott

Coroner name: Charlotte Keighley

Coroner Area: Cheshire

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Warrington Hospital

1    Warrington Hospital
I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 11 October 2023 I commenced an investigation into the death of David SCOTT aged 68. The investigation concluded at the end of the inquest on 23 May 2024. The conclusion of the inquest was that:  
David Scott died as a consequence of naturally occurring disease contributed to by malnutrition and in part by a delay in the initial diagnosis and treatment of peripheral vascular disease.
On the 2nd February 2023, David Scott attended Warrington Hospital with a history of a non-healing wound to his knee and leg pain. He was diagnosed with a right knee wound infection and discharged with antibiotics. On the 9th February 2023, David was seen by the physiotherapist who reviewed his x-rays and noted some vascular calcification, it was identified that David presented with risk factors for peripheral vascular disease and so it was requested that further investigations be carried out which resulted in an urgent referral being made to the vascular team on the 8th March 2023.   By the 4th April 2023, David’s knee wound had increased in size, showing no signs of healing, he was in pain and struggling with his mobility. At this time he had not had any communication in respect of the referral and so attended the Accident and Emergency Department at Warrington Hospital where the non healing ulcer on his right knee was noted, along with swelling and redness to both legs. David was admitted for review by the vascular team and on the 7th April 2023, investigations confirmed chronic limb threatening ischaemia in both of David’s legs in the context of peripheral vascular disease, at which time, surgical treatment options including revascularisation and endovascular were considered appropriate.   By the 14th April, David’s required assistance to mobilise and there was a deterioration in the wound to his knee with it appearing black and more inflamed with further blackened wounds appearing on his heel and ankle. During the period of deterioration, David’s wounds were not reviewed by the tissue viability nursing team as no referral had been actioned. On the 18th April 2023, David was treated with antibiotics for infection and when he was seen by the vascular surgeon on the 21st April, the condition of his leg had deteriorated to the point of ischaemic gangrene which had become so severe that he required an above the knee amputation as his leg was beyond repair. On admission, David was considered to be at high risk of malnutrition and during the admission, he lost weight following a reduction in his oral intake.
On the 26th April 2023, David was transferred to the Countess of Chester Hospital for surgery and on arrival it was noted that he had already started to develop deep tissue injury to his hip and buttocks. In the weeks that followed, amputation surgery was completed along with bypass surgery for revascularisation of his lower limbs. David continued to lose weight and experience difficulties with his skin integrity. He required 24 hour nursing care and was transferred to Green Park Nursing home to enable his wounds to heal with a view to his care eventually being moved back into the community. Whilst at Green Park, David gained weight and some of his wounds improved, however by the end of September, David was struggling to manage his pain, he looked pale and tests indicated that he had developed an infection.
On the 30th September 2023, David was admitted to Warrington Hospital with a diagnosis of infected ulcers and osteomyelitis. He did not respond to treatment and so palliative care commenced, following which, his condition deteriorated and he passed away on the 7th October 2023.
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
When Mr Scott attended Warrington Hospital on the 2nd February 2023, having been advised to do so by his GP and the GP having liaised with the hospital in respect of their concerns relating to a non-healing wound on Mr Scott’s knee, an x-ray was taken which showed evidence of vascular calcification which was not noted in the x-ray report. Mr Scott was diagnosed with a right knee wound infection and discharged with antibiotics.
Seven days later a physiotherapist reviewed Mr Scott and considered the x-rays as part of his review. The physiotherapist noted some vascular calcification on the x-ray, which raised concerns of peripheral vascular disease given Mr Scott’s clinical presentation and history.
Further information was provided to me in writing from a Consultant in Emergency Medicine and a Consultant Radiologist, as to why the vascular calcification was not recorded in the original x-ray report. I was informed that this was because blood vessel calcification can be a normal age related finding and the calcification was of minimal vascular calcification which could be normal.
Having considered the second edition of the Standards for Interpretation and Reporting of Imaging Investigations produced by the Royal College of Radiologists and having heard oral evidence from a Consultant Vascular Surgeon that a non-healing wound in addition to vascular calcification evident on x-ray can be a clinical indicator for Peripheral Vascular Disease which would then trigger a further process of investigation, I am concerned that a finding that ‘could be normal’ and so conversely ‘could be abnormal’ was not recorded.
I am further concerned and that something of this nature, would not be expected to be noted in the x-ray report, it appearing to be considered standard practice for it not to be reported by both a Consultant in Emergency Medicine and Consultant Radiologist within Warrington Hospital.
This does not appear to be consistent with expected standards and poses a risk that future deaths may occur.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by July 21, 2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
I have also sent it to
who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.
Charlotte KEIGHLEY Assistant Coroner for Cheshire