Mother died after QE medics failed to diagnose sepsis
Daughter’s anger after ‘significant failures’ in A&E led to blood poisoning being missed
AFIT and healthy Birmingham mother died after “significant failures and missed opportunities” at the Queen Elizabeth Hospital, an inquest has concluded.
Tracey Farndon, died only hours after admission to the hospital’s A&E department.
The 56-year-old was pronounced dead in the early hours of April 25 last year following a failure to properly identify and escalate signs of sepsis on arrival to the emergency department.
Had staff intervened earlier, Ms Farnson would not have gone into cardiac arrest and died that morning, the Senior Coroner for Birmingham and Solihull told the inquest.
Louise Hunt outlined ‘gross failings’ contributing to her death, which was caused by natural causes, contributed to by neglect and delayed diagnosis.
Ms Farndon had sought help at A&E in the early hours after feeling unwell for three days, with symptoms including vomiting, fatigue, worsening pain in her back and legs, and diarrhoea.
The emergency department was particularly busy that night and was understaffed, the inquest heard.
Basic tests were not sufficiently conducted and a blood pressure reading was not obtained.
Its significance was not detected by staff as Ms Farndon’s blood pressure was likely to have been too low for a reading to be picked up by the machine.
However, this was not investigated or escalated by staff.
It is likely the blood pressure reading would have resulted in a National Early Warning Score (NEWS2) of 2 to 3 – prompting an escalation of care, the coroner’s court heard.
It would have included blood tests, detecting developing sepsis and leading to a ‘sepsis 6’ treatment pathway, the court was told.
During the seven hours Ms Farndon was in the emergency department, she was not given a full assessment.
But she was deteriorating and was severely dehydrated, which was not detected.
She went into cardiac arrest and died that morning with her partner, Tom Parkin and daughter, Jess Sulmina by her side.
Speaking after the inquest, Ms Sulmina, who was pregnant when her mother died, said: “I am relieved by the Coroner’s decision and that I can finally feel a sense of justice following this shocking and devastating tragedy.
“I am glad that the University Hospitals
Birmingham NHS Foundation Trust has had to give answers for what happened the day my mother died and that there is a clear account of the deficiencies in the Emergency Department.
“What my mother went through in the final hours of her life was truly horrendous and I am completely heartbroken about the lack of care she experienced when she needed it most.
“I am glad that the Coroner has recognised the seriousness of what happened given that she concluded that my mother’s death was contributed to by gross failures amounting to neglect.
“I am still processing the whole tragedy, and the feelings of anger and disbelief are still with me to this day.
“Before I knew it, she was gone; I never got the chance to say goodbye.
“I was pregnant at the time, and it is gut-wrenching to think about the memories that could have been made with my mother had things turned out differently.”
She added: “I sincerely hope that lessons are learned so that no other family has to go through what we’ve been through.”
The feelings of anger and disbelief are still with me to this day Before I knew it, she was gone, I never got the chance to say goodbye. Daughter