Coroner warns of ‘chaotic’ conditions on understaffed hospital ward

A coroner has warned about ‘chaotic’ conditions on an NHS hospital ward opened to cope with winter pressures.

Sally Robinson, assistant coroner for East Riding and Hull, raised the issues in a Prevention of Future Deaths (PFD) report following the conclusion of an inquest into the death of 93-year-old Ethel Reed.

people wearing surgical clothes inside operating room

After a fall at her home in January 2023, Reed was taken to Hull Royal Infirmary with rib fractures, and was transferred to a new ward, Ward H130E, for physiotherapy. While on the ward she contracted Covid-19. After being assessed as not medically fit for discharge, she was wrongly discharged to a rehab centre, where she was placed on end of life care and died in early March.

Robinson focused her PFD report on the conditions at Ward H130, which had been opened in response to winter pressures.

‘At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing,’ Robinson wrote. ‘The ward [had] been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.

‘Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patents, their friends, or their families being able to have a clear escalation pathway to ventilate concerns.’

While an established team and leadership chain has now been put in place on Ward H130, Robinson warned of ‘a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.’

Robinson sent the report to Hull University Teaching Hospitals NHS Trust, NHS England and the Care Quality Commission, as well as the provider of an electronic patient record keeping system at the hospital.

Image: Piron Guillaume

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