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Anthony Searle secures neglect finding and 2 PFD reports in tragic sepsis inquest

8th April 2024

Anthony Searle, instructed by Sanja Strkljevic and Ella Cornish of Leigh Day, represented the bereaved daughter of Tracey Farndon at the resumed inquest into her death on 4 April 2024.

Tracey, an otherwise healthy 56-year-old woman, attended the Emergency Department at Queen Elizabeth Hospital in the early hours of 25 April 2023. She died the same day from septic shock, caused by sepsis secondary to community-acquired pneumonia. Not a single healthcare professional suspected sepsis at any point prior to Tracey’s death, despite signs being present.

Mrs Louise Hunt, HM Senior Coroner for Birmingham and Solihull, heard evidence from Tracey’s daughter and partner, as well as a Consultant in Emergency Medicine, a Consultant Thoracic Surgeon and an Emergency Department Matron.

Anthony’s questioning and legal submissions led the Senior Coroner to accept that there was sufficient evidence to justify the serious finding of neglect. The Senior Coroner considered that there was a gross failure to provide basic medical attention in the form of obtaining Tracey’s blood pressure reading and NEWS2 score shortly after her arrival. Had these gross failures not occurred, a different pathway would have been triggered, including a medical assessment of Tracey, various investigations, and the commencement of the Sepsis Six pathway. The Senior Coroner considered these gross failures to be causative of Tracey’s death.

As a result of the deficiencies in her care, Tracey was left without a full set of observations (and any repeat observations) for around 5 hours following her arrival, she had no medical assessment for over 6 hours, and she was never given antibiotics. The staffing levels and overcrowding in the Emergency Department were significant contributory factors hindering healthcare professionals’ ability to give Tracey the care she needed.

As well as making the rare finding of neglect, the Senior Coroner considered it appropriate to write two Prevention of Future Death (‘PFD’) Reports. The first will be sent to the Department of Health and Social Care because the Senior Coroner has serious ongoing concerns about resourcing in emergency departments. The second will be sent to University Hospitals Birmingham NHS Foundation Trust owing to a continued significant lack of understanding of sepsis.

The result of the inquest has been the subject of media attention (BBC, The Mirror, Birmingham Mail). The PFD reports are awaited and will be published here.

Anthony is a specialist in clinical negligence and healthcare-related inquests. He has significant experience in cases involving sepsis. His profile can be viewed here.

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