Phyllis Hart: Prevention of Future Deaths Report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 16/10/2024 

Ref: 2024-0563 

Deceased name: Phyllis Hart 

Coroners name: Emma Serrano 

Coroners Area: Staffordshire 

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

This report is being sent to: County Hospital Stafford 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
 
County Hospital Stafford;
Chief Coroner; and
Family of the deceased.
1CORONER
 
I am Emma Serrano, Acting Senior Coroner of Staffordshire.
2CORONER’S LEGAL POWERS
 
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.
3INVESTIGATION and INQUEST
 
On the 17th April 2023 2023, I commenced an investigation into the death of Mrs Hart.  The investigation concluded at the end of the inquest on 16 October 2024.  The conclusion of the inquest was a conclusion of natural causes. 
 
The cause of death was:  
 
1a) Sepsis,
1b) Acute Limb Ischaemia
1c) Peripheral vascular disease
II) Diabetes mellitus
4CIRCUMSTANCES OF THE DEATH
 
i) Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023.  On the 21 Marc 2023 she started to show signs of having a ischaemic leg.  On the 27th march vascular specialist review was requested.  There is no vascular team located on the County Hospital, so the review was delayed for 4 days until the Vascular Consultant was next at the County Hospital. 

ii) At the review, the decision was made that Mrs Hart was for palliative care only.  She passed away on the 8 April 2023
5CORONER’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.  –
 
There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required.     
6ACTION SHOULD BE TAKEN
 
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
7YOUR RESPONSE
 
You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 December 2024.  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.
8COPIES and PUBLICATION
 
I have sent a copy of my report to the County Hospital in Staffordshire and the family of Phyllis Christina Hart.  I am also under a duty to send the Chief Coroner a copy of your response.
 
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.
916 October 2024                                                  
Miss Emma Serrano
Acting Senior Coroner
Staffordshire