Matthew Baron recently represented the family of SR at an Inquest into their death. SR had been admitted to the Good Hope Hospital, Birmingham on 11th February 2023, following a fall at home.  

Initial investigations carried out upon SR’s admission indicated the presence of an infection. This finding was not identified or acted upon by treating clinical staff. SR then remained under the care of University Hospitals Birmingham NHS Foundation Trust from the date of admission until their death on 09th March 2023. Throughout this period, SR showed signs of confusion and later delirium, and their state generally deteriorated. Clinicians did not link their symptoms to an ongoing infection (and later sepsis) and anti-biotics were not started until 02nd March.

Further, SR experienced two falls whilst a resident on the ward in Birmingham Heartlands Hospital (on 15th and 27th February 2023), the first of which occurring whilst nominally on a 1:1 supervision regime. Both falls required surgery. Following the second surgical intervention on 03rd March, SR’s condition further deteriorated, and end of life care was started. SR sadly died on 09th of March due to the effects of ongoing urosepsis.

Following an Inquest at Birmingham Coroner’s Court, it was found that there had been a failure to carry out basic investigations into SR’s condition upon initial admission. The Coroner recorded that there were also several further missed opportunities to diagnose an infection and to start anti-biotics. It was also found that SR’s first fall on the ward was avoidable and should not have occurred. These failures, taken together, amounted to a “gross failure” to provide basic medical attention.

The Coroner therefore concluded that SR died as a consequence of untreated urosepsis, contributed to by falls and contributed to by neglect.

Matthew Baron was instructed by Kimberly James-Long of Lyons Davidson Solicitors.

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