Lina Piroli: Prevention of future deaths report
Hospital Death (Clinical Procedures and medical management) related deaths
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Date of report: 04/12/2025
Ref: 2025-0607
Deceased name: Lina Piroli
Coroner name: Melanie Lee
Coroner Area: Inner North London
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: NHS England | Department for Health and Social Care
| Regulation 28: Prevention of Future Deaths report | |
|---|---|
 THIS REPORT IS BEING SENT TO:1. NHS England 2. Department of Health and Social Care | |
| 1 | CORONER I am: Melanie Sarah Lee Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP |
| 2 | CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 3 | INVESTIGATION and INQUEST On 24 February an investigation commenced into the death of Lina Piroli, age 93 years. The investigation concluded at the end of the inquest on 1 December 2025. I made a determination at inquest that Lina Piroli suffered a multifactorial fall contributed to by naturally occurring age-related disease processes and an E. coli infection. |
| 4 | CIRCUMSTANCES OF THE DEATH Lina Piroli presented to the Whittington Hospital on 1 February 2025 with a two week history of feeling unwell, including a dry cough. Whilst a chest X-ray was clear, she had a raised heart rate, raised respiration rate, a temperature and slightly raised inflammatory markers. She was treated with IV antibiotics and fluids for a suspected chest infection and was discharged home on oral antibiotics in thee early hours of 2 February. Microbiology culture results were awaited. Lina re-presented to A&E by ambulance that evening following a fall down stairs at home. She was found to have an unstable fracture of C2 and a stable fracture of L1. Whilst in A&E, microbiology results were returned indicating an E.coli infection which was later confirmed, although the location of the infection was never established. She was already on the correct antibiotics and so treatment continued. After a long stay in A&E due to lack of a bed, Lina was transferred to a ward. Her pain and swallow were difficult to manage and she was presenting with delirium. She was unable to tolerate the hard collar and did not respond clinically to ongoing antibiotic treatment. Due to her age and frailty, her treatment became focused on comfort and she died whilst still an inpatient at the Whittington Hospital on 20 February 2025. |
| 5 | CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not unachievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old. Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery. I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care. |
| 6 | ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you and/or your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2026. 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the following. Family of Lina Piroli Whittington Health NHS Trust HHJ Alexia Durran, the Chief Coroner of England & Wales 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 other 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. |
| 9 | 4 December 2025 |