Press Statement re Tracey Ann South, deceased, by Rothera Bray Solicitors
Narrative verdict: Multiple missed opportunities by medical staff at King’s Mill Hospital led to failure to rescue patient.
Death 09.05.22 at King’s Mill Hospital
Inquest: 19.04.23 at Nottingham Coroner’s Court
Coroner: Laurinda Bower
Finding: Narrative verdict – multiple missed opportunities by medical staff between 27 April 2022 and 5 May 2022 leading to a failure to rescue the patient who would likely have lived longer had she received appropriate treatment
Represented by: Julie Walker, Consultant & Solicitor, Rothera Bray Solicitors (Serious Injury Team) – j.walker@rotherabray.co.uk
Alexandra Pountney, Counsel, The Ropewalk Chambers, Nottingham – clerks@ropewalk.co.uk
Tracey South was not dealt the easiest cards in life. Having suffered with spina bifida, she spent her life in a wheelchair, but this did not dampen her grace, courage or strength.
Those clinicians who regularly and routinely treated and cared for Tracey will say how pleasant she was and how they will miss her smile as she wheeled herself into their clinic.
This pales against the devastating loss which Tracey’s family suffered following her death in hospital on 9 May 2022.
Tracey was just 51 years of age at the time of her death. She was admitted to King’s Mill Hospital on 22 March 2022 following her carer’s concerns that she seemed weaker than normal and had fallen out of her chair. She remained on Ward 34 until 26 April 2022 when she was transferred to an ‘outlier’ ward due to bed pressures, before being discharged home on 3 May 2022.
At the time of her discharge, Tracey had not been seen or reviewed by a Doctor for 5 days.
The following day, 4 May 2022, Tracey was an emergency readmission back to King’s Mill Hospital, and sadly by the time she was properly reviewed she was deemed to be too unwell to be rescued. In short, Tracey was beyond medical help at this juncture. She tragically died on 9 May 2022, at King’s Mill Hospital, having been placed on an end-of-life pathway.
It appears clear that there were a number of missed opportunities, and failings by medical staff, which meant that they did not rescue Tracey. They had not recognised the key issues requiring urgent treatment and delayed in providing her with fluid resuscitation and other medication in good time. Despite her kidney injury, the acute kidney injury treatment bundle was not provided to her in a timely manner, and there were a number of service delivery problems including a failure to repeat bicarbonate levels, to repeat blood tests, a lack of consultant review and no highlighting of outstanding jobs at the times of transfer which meant potentially lifesaving treatment was overlooked or delayed. Communication was also lacking and infrequent, both between staff, and with Tracey’s family who were desperate for news of her health in a Covid era where visiting the ward was not routinely permitted.
Whilst the family note the recommendations made by King’s Mill Hospital following their own investigation into Tracey’s untimely death, they are keen that these lessons must be learnt, and her death must not be in vain. Acute Kidney Injury is a medical emergency and must be treated as such. Tracey’s family hope that the findings at inquest help to safeguard other vulnerable patients in the future.
The family wish to express their thanks to the Coroner and their officers for their time, care and attention in closely examining the circumstances which led to Tracey’s death.
Julie Walker, Serious Injury Consultant and Solicitor at Rothera Bray Solicitors 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’.
Associated press related to the inquest can be found here: https://www.bbc.co.uk/news/uk-england-nottinghamshire-65373712
