Kim Stroud: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 22/02/2024

Ref: 2024-0105

Deceased name: Kim Stroud

Coroner name: Yvonne Blake

Coroner Area: Norfolk

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

This report is being sent to: Queen Elizabeth Hospital

Chief Executive Queen Elizabeth Hospital Gayton Road King’s Lynn Norfolk PE30 4ET
I am Yvonne Kathleen Blake, Area Coroner for the coroner area of Norfolk.
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and requlations 28 and 29 of the Coroners (Investiqations) Regulations 2013.
On 27 October 2022 I commenced an investigation into the death of Kim Georgina STROUD aged 65. The investigat ion concluded at the end of the inquest on 14 February 2024.  

The medical cause of death was:
la) Idiopathic Pulmonary Fibrosis
2) Bladder Cancer, Covid Pneumonia  

The conclusion of the inquest was:   Natural causes.
Mrs Stroud was admitted to hospital on 4 August 2022 for a transurethral resection of bladder tumour which had been cancelled 5 times. She became unwell on 15 August 2022 with a chest infection against a background of severe interstitial lung disease and chronic type 1 respiratory failure . She tested positive for covid on 10 September 2022. Despite being on multiple antibiotics for chest infections and all other treatment she remained on high oxygen demand and was episodically confused. She died suddenly on 11 October 2022.
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)  
Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication. Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table . These had been siqned for as qiven. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being  poisoned, clearly not supervised in taking those either. It  was extremely  unsafe to  leave tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked  them up. On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was  dripping  off the  edge  of the  bed and the  family  had to wash and change her themselves. Also wash faeces from her body.
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 April 18, 2024. I, the coroner, may extend the period.
Your response must contain details of act ion 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 [REDACTED] (Daughter)
The Nursing and Midwifery Council
I have also sent it to
Department of Health Care Quality Commission HSIB
Healthwatch Norfolk
NHS England and NHS Improvement
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.
922 February 2024
Area Coroner for Norfolk.
County Hall Martineau Lane Norwich NRl 2DH