UK Inquiry Tracker

Margaret Warwick

PFD Report Historic (No Identified Response) Ref: 2022-0243

Date of Report 4 August 2022

Coroner Alison Mutch

Coroner Area Manchester South

Response Deadline est. 25 November 2022

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, and further compounded by theatre capacity and High Dependency Unit bed shortages.

View full coroner's concerns

1. The Inquest heard that under the NICE guidance where a patient needs an operation for a hip fracture such as in Mrs Warwick’s case and needs optimising, that optimisation should be dealt with expeditiously. In Mrs Warwick’s case she needed cardiology assessment. That delay was due in part to a shortage of cardiologists at the trust exacerbated in particular by a lack of cover by cardiologists over weekends and OOH. The Inquest heard that there was no facility for a patient such as Mrs Warwick to be assessed by cardiology over the weekend;
2. Even after the assessment the Inquest heard evidence that there was a further delay due to a shortage of theatre capacity at the Trust.
3. The delay was further compounded by a shortage of HDU beds at the Trust. The Inquest heard that the Trust was trying to manage this but this shortage was part of a national shortage of HDU beds.

Sent To

Department of Health and Social Care

Response Status

Linked responses 0 of 1

56-Day Deadline 25 Nov 2022

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 10th March 2022 I commenced an investigation into the death of Margaret Ena Warwick. The investigation concluded on the 15th July 2022 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Acute Myocardial Infarction; 1b) Operative repair right neck of femur fracture; II) Ischaemic heart disease, Left ventricular dysfunction

Circumstances of the Death

Margaret Ena Warwick lived independently. She had significant ischaemic heart disease and left ventricular dysfunction. She had previously had a myocardial infarction. She was not a suitable candidate for heart surgery. On 23rd February 2022 she had an accidental fall at home. She was taken to Tameside General Hospital where a fracture to the neck of femur requiring surgery was identified. A suspected pulmonary embolism was ruled out. There was an identified need for a pre-operative cardiac review, which did not take place until 28th February 2022. An MDT took place on 1st March and it was agreed a HDU bed was required. A shortage of beds meant surgery was delayed until 3rd March 2022. She initially made a good recovery post operatively but then began to deteriorate. She died at Tameside General Hospital on 7th March 2022.