Concerns over patient safety at a Norfolk hospital have been raised after a retired teacher died alone in a side room, out of sight of staff who had not checked she could use her call bell.
It follows an inquest into the death of Jeanine Huggins, from Norwich, who was found unresponsive on a ward at the Norfolk and Norwich Hospital (N&N).
The 68-year-old was being treated for neutropenic sepsis after being admitted to the N&N on May 3, 2022, suffering from side effects of chemotherapy for stage 2 non-Hodgkin's Lymphoma.
Area coroner, Samantha Goward, explained that while it was necessary for some patients to be placed in side rooms, appropriate risk assessments needed to be carried out.
She said: “The care provided in relation to Jeanine was appropriate and a clinical picture was showing signs of improvement.
“They were making plans for discharge.
“However, all evidence was that she could not been seen from the door so her only way to communicate any needs to staff was via the call bell.
“This made it vitally important that when she was left it was checked so that she could reach it and check that she could activate it.
“While I accept that the bell was placed within reach, it was not checked that she could use it before she was left alone in that room.
“This did not happen on the evening of May 9.”
An inquest into her death heard she had last been checked on by staff at 11pm on May 9.
But three hours later, staff found her unresponsive in the side room she was being treated in. Efforts to resuscitate her did not succeed.
At the time of her death, the Mulbarton ward had just two nurses on shift to care for 34 patients, after one had left sick at midnight.
Ms Goward stated that a lack of risk assessment “may pose a risk” to other patients who are placed into side rooms.
She added: “I was told that there is no risk assessment carried out when someone is placed into a side room.
“I fully accept there are many reasons why a side room is necessary, including in cases like Jeanine where a patient is vulnerable and there is risk of infection.
“However, if there is no risk assessment then this may pose a risk.
“And the evidence was that it was not checked if Jeanine could use the call bell.”
Summing up the evidence at a two-day inquest into Mrs Huggins' death, which was held at the Norfolk Coroner’s Court this week, Ms Goward issued a Prevention of Future Deaths report.
She highlighted positive steps taking place at the N&N, including raised staffing levels and the appointment of a dedicated clinical educator.
But said she remained “concerned” about patient safety.
“While I didn’t find that they were causative in Jeanine's death,” she added, “I am concerned.
“It is an on-going concern that there is not any risk assessment carried out prior to leaving someone in a room on their own to make sure they can safely attract attention to staff in the event of an emergency.
“The call bell for people like Jeanine is the only way to attract attention if something is happening.
“I think that if there was a risk assessment in place this would ensure that any issues that someone has with regards to reaching or pressing call bells are clearly considered and documented and can be handed over on each shift and checked.”
Ms Goward concluded that Mrs Higgins died from natural causes, with the primary medical cause of death given as coronary artery atheroma – which was only discovered following her death.
During the inquest, Mrs Higgins husband, John Huggins, had raised concerns about the treatment his wife received during her seven-day admission at the hospital.
He said: "My life was shattered knowing that my wife of almost 50 years died on her own.
"This will live with me for the rest of my life."
Prof Nancy Fontaine, chief nurse at the N&N, said: “Our deepest condolences are with the family of Mrs Huggins, and we are very sorry that opportunities were missed to escalate her deteriorating condition.
“A full and thorough internal investigation took place following her death at the N&N and recommended further education take place around the importance of nursing staff escalating deteriorating patients and NEWS2 (National Early Warning Score) as per Trust policy.
“We shared our report with the family, and we are happy to speak with them further if they have any additional questions or concerns.”
- To pay tribute to a loved one, email norfolkobituaries@newsquest.co.uk
- To read all obituaries and tributes join the Facebook group Norfolk's Loved & Lost.
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