Neglect contributed to mum's death, inquest finds.

A woman's death in hospital was from natural causes but neglect was a contributory factor, an inquest has found.

Tracey Farndon, 56, died of sepsis at the Queen Elizabeth Hospital, Birmingham, in April 2023 but the condition was not discovered until after she died.

She had waited five hours for routine observations to be taken which could have led to a faster diagnosis and treatment, her family said.

Senior coroner for Birmingham and Solihull, Louise Hunt, said she would write to the Department of Health and Social Care because an overwhelmed emergency department contributed to her death.

She will also write to the trust which runs the hospital about concerns that sepsis was not considered an issue until after Ms Farndon died.

The coroner said a nurse could not complete a full set of observations and, while the nurse claimed Ms Farndon could not keep still, Ms Hunt found that was not the case.

The coroner said that, on the balance of probabilities, Ms Farndon's blood pressure was not recorded because it was too low on admission to hospital.

She added that no observations were repeated for five hours and overcrowding in the emergency department at the time was a significant factor in the failure to give Ms Farndon the care she needed.

The coroner said: "I am satisfied that she was suffering from sepsis when admitted to the emergency department."

She added that medics also failed to record Ms Farndon's blood pressure.

The coroner recorded a narrative conclusion and said: "Tracey died from natural causes contributed to by a delay in diagnosis and treatment. Her death was contributed to by neglect. I am still concerned about a genuine lack of understanding about sepsis.

"It does seem to me that there was a particular lack of understanding here because it was not considered by anybody until after her death.”

A serious incident investigation by the trust had already looked at the circumstances surrounding Ms Farndon’s clinical management. 

The report, seen by the BBC, said incomplete observations were caused by “reduced staffing against the volume of patients and acuity of the department."

Sepsis was not considered as part of the differential diagnosis, so antibiotics were not prescribed, the report said.

It added that repeat patient observations may have led to "earlier identification of the patient's deterioration" as well as "earlier escalation" to the nurse in charge and doctor and commencement of sepsis screening.

University Hospitals Birmingham consultant in emergency medicine, Dr Jitender Monga, said: “The service was stretched, long waits. It probably did contribute to Tracey being seen quite late. The failure to take blood pressure was a serious failure.

"Overcrowding is probably one of the major factors. A number of patients were waiting for hours and hours in the department."

Another medic, Dr Richard Stein, added: "We missed giving her the opportunity for treatment. I am sorry that that happened. I express my apologies on behalf of the trust but can’t change what happened. She was in the wrong place. We needed to get her through to majors much, much sooner.

"Would treating her for sepsis have changed her survival to leaving hospital? We just truly don’t know."

After the inquest, Ms Farndon's daughter, Jess Salmina, said: "What my mother went through in the final hours of her life was truly horrendous. We are all completely heartbroken as a family about the lack of care she experienced when she needed it the most. I think it’s too early for forgiveness at this point."