Coroner voices concerns over woman's death at Rotherham Hospital
She passed away 10 weeks after being admitted for a broken hip last year
A coroner has voiced concerns over the death of a woman who died 10 weeks after being admitted to Rotherham District General Hospital for a broken hip.
Louise Slater, coroner for South Yorkshire East, has raised the issue with the Rotherham NHS Foundation Trust following the death of Anne Hawkes on the 15th of July 2023, as a consequence of multi-organ dysfunction due to an infected hip joint.
Ms Slater concluded that the infection occurred due to surgical wound breakdown because of pressure caused by fluid overload as a result of ‘poorly managed’ cardiac failure.
The coroner ruled that a ‘lack of communication’ between services within the Trust led to a ‘delayed and incohesive approach to the wound management’.
Mrs Hawkes was admitted to Rotherham District General Hospital on May 3, 2023, following a fall at home.
She recovered well after surgery for her broken hip the following day, and was medically fit for discharge by May 11, but remained on the orthopaedic ward whilst awaiting social care input.
However, Ms Slater’s prevention of future deaths report found that Mrs Hawkes’s cardiac failure ‘was not monitored by way of fluid balance charts or daily weights’ – and she had gained 34 kg by May 22.
The increase in weight was only acted upon on May 17, when a referral to cardiology was made, but by this time she was ‘very unwell with fluid retention, hyponatremia and deteriorating renal function’.
Mrs Hawkes was seen by specialist cardiac failure nurses on May 22 and was given IV medication to deal with the excess of fluid.
She was transferred to the cardiology ward on May 25, and despite the wound starting to break down on June 3, a referral to tissue viability was not made until the 29th.
By this time, tissue viability were unable to assist, and a surgical washout was declined by Mrs Hawkes, so the wound was managed with dressings and antibiotics. She deteriorated and died on July 15, as a consequence of multi-organ dysfunction.
The coroner reported that the infection had occurred due to the surgical wound breaking down, due to pressure caused by fluid overload, as a result of ‘poorly managed cardiac failure’.
She found that the delayed referral to cardiology whilst Mrs Hawkes was on the orthopaedic ward led to ‘sub optimal management of her cardiac failure, which in turn is implicated in her death’.
The coroner found ‘no procedure in place at the Trust for Clinicians to automatically refer in-patients with known cardiac failure to cardiology for expert management.
Her report added that the ‘lack of communication’ between the surgical, cardiology and tissue viability services ‘led to a delayed and incohesive approach to the wound management’.
The report has been sent to the NHS trust, as well as Mr Parks’ family.
The organisations must respond by May 28 with details of action taken or proposed to be taken, setting out the timetable for this to happen, or they must explain why no action is proposed.
Dr Jo Beahan, medical director at The Rotherham NHS Foundation Trust, said: “Our thoughts and condolences are with Anne’s family and friends at this sad time.
“We take these matters very seriously. We have taken on board the findings of the report and will be taking steps to address the concerns identified.
“We do have processes in place within the trust for clinicians to refer patients for urgent cardiology advice. We will be reviewing why this did not happen for Mrs Hawkes and ensuring we take appropriate actions to prevent this happening in future.”