Virtual ward referral could have prevented teenager’s death

Poor understanding and a failure in a trust’s virtual ward process contributed to the death of a 19-year-old man, a coroner has found.

The failure to refer to the virtual ward team, and misunderstanding about the team’s suitability, caused or contributed to the death of Isaac Arrowsmith, who was treated by East Cheshire Trust earlier this year.

According to a Prevention of Future Deaths notice, Mr Arrowsmith had haemoglobin Rainier disease – a condition that increases the risk of blood clots.

He attended hospital four times between 19 December 2025 and 1 January 2026 with chest pain and after coughing up blood, and was discharged each time, with clinicians concluding he had a chest infection or pneumonia.

On his third attendance on 31 December, a doctor decided to send Mr Arrowsmith home. He decided he should be under the care of the respiratory virtual ward team, for follow-up in 48 hours.

However, no referral was made to the virtual ward team that day.

The coroner found that, had the referral been made and the VW team considered it, the team would have rejected it and advised that Mr Arrowsmith should remain in hospital, because it was not appropriate for the virtual ward.

Instead, the patient deteriorated at home on 2 January and could not be resuscitated by paramedics.

The coroner concluded that, had he been admitted to hospital, “he would have been in hospital at the time of his deterioration on 2 January and would have been successfully resuscitated”.

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Source: HSJ, 17 August 2026