UK Inquiry Tracker

Elsa Reid

PFD Report Historic (No Identified Response) Ref: 2019-0139

Date of Report 2 April 2019

Coroner Zafar Siddique

Coroner Area Black Country

Response Deadline ✓ from report 27 May 2019

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.

View full coroner's concerns

1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented.

2. Although it is recognised some bed bound exercises were completed there was insufficient urgency amongst those professionals involved to resolve the matter as quickly as possible and thereby reduce the risks of complications, including pulmonary embolism from developing.

Sent To

New Cross Hospital NHS Trust
Wolverhampton City Council

Response Status

Linked responses 0 of 2

56-Day Deadline 27 May 2019

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 the 28 December 2018, I commenced an investigation into the death of Mrs Elsa Reid. The investigation concluded at the end of the inquest on 8 March 2019. The conclusion of the inquest was a short form conclusion of accidental death.

The cause of death was:

1a Pulmonary Embolism b Left Femur Fracture-Open Reduction and Internal Fixation c Fall II Urinary Sepsis, Hypertension, Type 2 Diabetes Mellitus, Cerebrovascular Accident

Circumstances of the Death

i) Mrs Reid was a 92 year old woman who was admitted to New Cross Hospital on the 30 October 2018 after a fall at home and sustained a complex fractured hip. This was surgically repaired in Hospital and post operatively she made adequate recovery. ii) Whilst in Hospital, she was given physiotherapy and encouraged to increase her mobility with an exercise regime. The purpose of the latter treatment was designed to reduce risks associated with immobility including the development of a pulmonary embolism. iii) She was later discharged on the 30 November 2018 to Eversleigh Care Home which acts as step-down temporary facility to allow rehabilitation. iv) There was some conflicting information provided upon discharge on whether she should be hoisted and allowed to sit in a chair and frequency of mobility exercises. Specifically, the occupational therapist sent an email to the Consultant in charge on the 11 December (some 12 days after discharge) to clarify the conflicting information regarding weight bearing or non-weight bearing and whether the patient needs hoisting. The consultant

[IL1: PROTECT] responded by stating that she shouldn’t be hoisted. v) On the 19 December her condition declined rapidly and she was re-admitted to the same hospital. vi) Sadly she died after developing a pulmonary embolism on the 20 December 2018.

Action Should Be Taken

1. The Hospital Trust in conjunction with Wolverhampton City Council may wish to consider urgently reviewing the protocols in place during discharge of patients to step-down care. In particular, the information provided during the discharge process and contacting the lead Consultant where clarity is needed.