A Nottinghamshire hospital has apologised to a woman's family after staff missed opportunities to treat her before her death. Tracey South, 51, died in King’s Mill Hospital on May 9, 2022 after being admitted on March 22, 2022 due to her carer’s concerns that she seemed weaker than normal and had fallen out of her wheelchair.
Miss South had spent her life in a wheelchair, due to having spina bifida, a type of neural tube defect. She remained in a hospital ward until April 26, 2022 suffering from a kidney injury, after which she was transferred to an ‘outlier’ ward due to bed pressure and then discharged home on May 3, 2022.
An inquest into her death was held on April 19 at Nottingham Council House. It heard that the following day after she had been discharged from hospital, she was an emergency readmission into King’s Mill Hospital and was too unwell to be saved. She died on May 9, 2022 after being placed on end-of-life care.
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Coroner Laurinda Bower found there were a number of opportunities missed by medical staff, concluding Miss South would likely have lived longer had she received different treatment.
Sherwood Forest Hospitals, which runs King’s Mill Hospital, apologised to Miss South's family after the inquest. It explained steps had been taken to address the concerns raised by the coroner's inquiry and its own internal investigation.
Changes implemented as a result include taking steps to improve the communication between medical teams and patients’ families while patients are in hospital and strengthening the clinical oversight and review of patients who are re-admitted into hospital having previously been discharged.
Dr David Selwyn, medical director for Sherwood Forest Hospitals, said: “We would like to express our deepest condolences to Miss South’s family for their loss and offer them an unreserved apology at what we know will be an incredibly difficult time for them.
“We are committed to providing the best possible care to all our patients and we welcome the level of scrutiny of the time that Tracey spent in our care. We have conducted our own internal investigation into this case and have fully supported the coroner’s inquiry as two key parts of understanding the circumstances surrounding Tracey’s death.
“Those investigations highlighted a number of areas where we could have provided better care. We must learn the lessons from this case and, as a result of those investigations, we have already taken steps to address the concerns raised to ensure we are continuing to provide the best possible care to our patients in future.”
Julie Walker, consultant and solicitor at Rotheras Solicitors, who represented Miss South's family, said: ‘Tracey’s family have shown great strength since her death. It has been a lengthy and difficult process for them. I am pleased that the Coroner recognised that there were missed opportunities by King’s Mill, and I hope that lessons are now learnt.
"Ensuring that questions were answered at the inquest, and responsibility was taken, was the last thing which the family could properly do for Tracey. I hope that they now feel they have some of the justice which they deserve for her’.
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