Prevention of Future Deaths report: Tamara Davis (15 October 2024)

Summary

Tamara Davis died on 13 December 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from multi organ failure which developed due to bronchopneumonia caused by influenza A infection. She had been admitted to hospital on 10 December 2022 having been unwell for 5 days.

She was assessed in Resus within the Emergency Department (ED) when her NEWS score was 8. She was treated for a suspected chest infection with IV antibiotics, fluids and paracetamol in the early hours of 11 December. Her clinical condition then appeared to be improving. She was moved into the ED corridor at 05:30 on 11 December as this was in use for patients. She then waited to be admitted to a ward for further treatment and observation. She remained in the ED corridor until 15:20 on 11 December.

Tamara then moved to a cubicle in Majors within the ED and thereafter she experienced a significant deterioration in her condition which was treated and resulted in her admission to Intensive Care Unit. Despite treatment with supportive therapy she died on 13 December 2022.

Content

Coroner's matters of concern

• During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
• Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary.
• I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
• I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.