Matthew Phipps
PFD Report
Historic (No Identified Response)
Ref: 2023-0219
Coroner's Concerns (AI summary)
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
View full coroner's concerns
A concern arose at the Inquest hearing in relation to the lack of a contingency plan in place to ensure that intensive care is provided to all patients who require it, but where the intensive care unit itself is full. The Inquest heard evidence from an independent consultant anaesthetist who stated:
I do not understand why one or two of the 8 ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU. It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures.
The Trust were aware of this concern, but did not provide any evidence to address this.
I do not understand why one or two of the 8 ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU. It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures.
The Trust were aware of this concern, but did not provide any evidence to address this.
Sent To
- Barking, Havering and Redbridge University Hospital NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
25 Aug 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 4 October 2022 I commenced an investigation into the death of Mr Matthew John Phipps, aged 56 years. The investigation concluded at the end of the inquest on the 26 June 2023. The conclusion of the inquest was that Mr Phipps died from natural causes.
Circumstances of the Death
On the 10 July 2022, Matthew Phipps was admitted to Queens Hospital with a severe, acute kidney injury and a 5 day history of fever, chills, diarrhoea and vomiting. On the 10 July 2022 he also presented with lower abdominal pain, lower back pain and pain in the top of his right leg. He was recognised as being critically unwell and the emergency department requested transfer to the intensive care unit. There was a delay in transferring Matthew to intensive care. He should have been transferred by 2230 on the 10 July 2022, but was not transferred until 0930 on the 11 July 2023. Matthew's family observed that only one of two bottles of antibiotics prescribed to Matthew in A&E were administered to him. Matthew was not observed as closely as he should have been, given his very concerning clinical condition and there were delays in carrying out necessary blood tests and in commencing renal replacement therapy. The inquest has found however that Matthew presented to hospital on the 10 July 2022 with a likely acute kidney injury, associated with sepsis. As such, his prognosis was very poor, even with optimal treatment. There is no evidence that the failings in the care provided to him contributed to his death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.