Coroner's concern over pensioner's death from sepsis

Alan Walsh, the Bolton assistant coroner, has questioned why routine observations were not carried out on Patricia Forshaw, who had a leg wound.

Mrs Forshaw, from Wigan, was taken to the hospital in October 2016 after suffering a fall in the garden, an inquest heard earlier this year.

She was treated at the infirmary and released with an outpatient appointment card for two days later, the court was told.

But the following day her husband Ted called the hospital, due to his wife experiencing considerable pain, using a number given on the card, and was told to administer paracetamol.

The inquest heard that by the following day, when the outpatient appointment took place, her leg had become swollen and there was an offensive smelling discharge from the wound.

She arrived an hour early for her appointment and her family asked if there was a triage nurse who could assess the pensioner, as she was in “substantial pain”, the court was told.

But Mrs Forshaw had to wait another hour to be seen by a doctor, who believed the wound may have become infected and sent her home after issuing a prescription for antibiotics.

Her condition deteriorated, on her return home, with the discharge continuing from the wound, prompting her son to call the emergency department at the hospital. He was told that the hospital would only redress the leg and he was advised to seek assistance from the district nurse.

Later the wound was assessed by her GP and she was referred to the district nurse, the inquest heard.

But in the early hours of the following day she suffered a cardiac arrest and died shortly after her arrival at Wigan Infirmary.

Coroner Mr Walsh was told that the cause of death was sepsis and an infected wound in Mrs Forshaw’s lower right leg.

His conclusion was the death was due to “injuries sustained in an accidental fall where vital observations and a further investigation were not conducted following a deterioration in her condition arising from a developing infection”.

Mr Walsh wrote to hospital chief executive Andrew Foster to express concerns about the “ambiguity” of the appointment card handed out, the advice given when the husband rang the following day, the fact the wound discharge was not recorded in her notes, that basic observations were not carried out at the out-patient appointment and that a serious review had not been conducted after the death.

One witness, giving evidence, said there had been a “gross miscommunication” in Mrs Forshaw’s case.

In a response to the coroner, Mr Foster said the appointment card would be redesigned to advise patients to ring 111 or a GP if they had ongoing concerns.

He also said a doctor had noted Mrs Forshaw’s wound, although it had not been documented by a nurse.

The coroner was told it would not be possible to introduce a policy covering routine observations for outpatients appointments, as “patients attend with a vast range of symptoms” and it was standard practice to allow doctors to give advice based on individual presentations.

A spokesman for Wrightington, Wigan and Leigh NHS Foundation Trust said: “The trust always strives to provide safe, effective and compassionate care to all patients and deeply regrets that this was clearly not the case for Mrs Forshaw.”

“Several changes have already been made which will be monitored through the appropriate committee. The trust has learnt lessons from this incident which will benefit other patients in the future.”