Concerns raised over weekend services after 61-year-old's death at Colchester Hospital
A coroner has flagged dietetic service gaps in report on the hospital death.
A lack of weekend dietetic services at Colchester General Hospital has been highlighted in a coroner's review following the death of a 61-year-old woman.
Suzanne Pemberton passed away on 16th September 2024 due to pneumonia and sepsis, exacerbated by bronchiectasis, severe depression, malnutrition, and chronic frailty, according to the report.
Suzanne had been admitted to the hospital on 12th September 2024 and referred for priority evaluation by the Dietetic team on 13th September, with guidance to be assessed within 24 hours. However, the report states she was not fully assessed in person before her death.
An inquest into her passing concluded that while this did not directly cause her death, the lack of weekend dietetic services was flagged as a concern.
Essex coroner Sean Horstead noted that the inadequate care and management provided by Essex Partnership NHS Foundation Trust likely contributed to Suzanne's worsening condition.
He stated that inadequate escalation of her mental health concerns, flagged by clinicians treating her chronic bronchiectasis over the two years prior, created a pattern of repeated hospital admissions.
"This, in turn, directly contributed to the exacerbation of her chronic lung condition, leading to repeated infections and, ultimately, the fatal pneumonia and sepsis," Horstead said.
He added that by Suzanne's final admission on 12th September, her physical and nutritional state had declined to such a degree that her death four days later was unlikely to have been avoidable.
Currently, Colchester General Hospital does not offer dietetic services on weekends or bank holidays. Dietetic Professional Lead confirmed that these services are available only during weekday working hours from 8am to 5pm.
Giving evidence at the inquest, she described this gap as “far from ideal” and said it could mean delayed naso-gastric feeding for patients.
Catherine Morgan, chief nurse at East Suffolk and North Essex NHS Foundation Trust, which operates Colchester General Hospital, said: "Our priority is to provide the highest standard of care for all our patients. We will review the Prevention of Future Death report and recommendations set out by the coroner."
Essex Partnership NHS Foundation Trust has yet to comment on the report.