Coroner to consider whether lessons can be learned by hospitals after the death of student nurse Zoe Bell following 12-hour wait in A&E

Senior Coroner for Buckinghamshire, Crispin Giles Butler concluded that Zoe died from flu combined with Staphylococcal Aureus Septicaemia (secreting the PVL toxin), Bronchial Pneumonia and an acute lung injury which were not treatable by the hospital in the timescale from her arrival there. 

Finding that Zoe died from natural causes, the coroner said, “nothing I will say, can diminish the loss of a previously healthy lady, who aspired to a career in nursing to help others”. 

Zoe, from High Wycombe, died 20 hours after arriving at Stoke Mandeville Hospital where she worked shifts. She had spent more than 12 hours in the A&E department waiting for a full clinical assessment. During that time, her boyfriend pleaded with hospital staff to give her care, the coroner was told at Beaconsfield Coroner’s Court. Despite this, Zoe remained in the A&E waiting area.

Zoe Bell

It was only after Zoe’s condition seriously deteriorated and her x-rays were reviewed at 10am on Christmas Eve that she was rushed to a resuscitation bay before being taken to the intensive care unit. Tragically, Zoe died in surgery at 6.45pm that day. 

In hearings in October and on Wednesday 11 and Thursday 19 December, the coroner heard evidence from Zoe’s family’s legal team that earlier investigations could possibly have prompted earlier interventions and changed the outcome of her treatment. 

The coroner is considering whether he will publish a Prevention of Future Deaths report. In his comments, he highlighted that during Zoe’s time in the emergency department, observations should have been recorded regularly and that if they weren’t, this would be an area for learning 

In a statement read outside court following the conclusion of the inquest, Zoe Bell’s father Nick Bell said:

“Following the sudden and heartbreaking passing of our beloved Zoe on Christmas Eve 2022, we, her family, would like to thank all those who have supported us through this incredibly painful time. 

“At just 28 years old, Zoe had her whole life ahead of her. She fell ill after suffering from the flu for four days, which developed into severe infections of staphylococcus aureus, pneumonia, and sepsis. Tragically, Zoe passed away within 20 hours of attending the hospital where she worked and devoted her time and energy to caring for others. 

“Throughout her life Zoe’s kindness, humour, and caring nature left a lasting impact on everyone who knew her. She was a source of strength and joy for her family and friends and words cannot capture the depth of our loss. 

“Zoe had a bright future ahead. As a student nurse in her final year, she was excelling in her studies and was passionate about caring for others. We know she would have gone on to do more incredible things in her nursing career. 

“Zoe’s sudden passing was caused by complications from flu, worsened by the rapid onset of additional serious infections. We hope that this will raise awareness of the serious risks associated with these illnesses, especially in otherwise healthy young people and how urgent diagnosis and treatment are essential. 

“Zoe was a beautiful and delicate young woman with so much potential, her absence leaves a hole in our lives that can never be filled. But we know Zoe’s legacy, the kindness and love she showed others, will live on in those lives that she touched. We will forever cherish our memories of her and carry her in our hearts always. 

“We want to express our deepest gratitude for the support we received from friends, family, and the wider community during this incredibly difficult time. Your love has carried us through, and we ask for privacy as we continue come to terms with our loss. 

“It is our heartfelt wish that lessons can be learned from Zoe’s death and that changes are made to the way A&E departments are run. 

“The coroner has indicated that he will now take time to consider these. 

“We want doctors to have greater awareness of the symptoms of infections in healthy young people who can sometimes mask these signs. 

“We want medics to take greater account of the concerns of patients and their families, who may be best placed to notice changes in their loved one’s condition. 

“And we want A&E units to examine patients more quickly and for their symptoms to be recognised and treated with more urgency. 

“Now that the inquest process has concluded, it is still difficult to comprehend that  an otherwise healthy 28-year-old can go to A&E and pass away within 20 hours. 

“In relation to Zoe’s case this has highlighted the importance of the learning on how young people can compensate on how ill they actually are, the importance of listening to patients and family, the importance of regular observations being recorded to monitor deterioration and the importance of timely x-rays being acted upon. 

“It is our hope and wish that urgent action is taken in light of Zoe’s death so that no other family has to go through a similar tragedy in future.” 

Zoe Bell

The inquest into Zoe’s death was held from 30 September and ran across six days, with the conclusion given on Thursday 19 December. 

Zoe’s family was represented at the inquest by solicitor Megan George of law firm Leigh Day. 

Megan instructed Rachael Gourley of Serjeants’ Inn Chambers who questioned managers from Buckinghamshire Healthcare NHS Trust at the inquest. 

In evidence, Dr Andrew McLaren the trust’s Chief Medical Officer said that it was a “very tragic case” and that Zoe’s death led to a review of staffing, procedural and training levels within the emergency department at Stoke Mandeville Hospital the findings of which he said have now been acted upon. 

Following the conclusion of the inquest, solicitor Megan George of Leigh Day said: 

“The evidence heard in this tragic inquest has highlighted the importance of monitoring patients in the Emergency Department and recording regular observations, to help clinicians identify deterioration in patients’ conditions at an earlier stage.  

“It has also shown the importance of listening to patients and their families, who may be able to recognise signs that their loved one’s condition is getting worse, particularly in young, otherwise healthy, people who can ‘mask’ their symptoms.  

“It has been an honour to represent this brave family, who have sought to get answers about how Zoe could have deteriorated overnight in the Emergency Department of the Hospital where she worked. I, along with the family, hope that the evidence heard during this inquest can help those working in emergency settings learn from potential failings in Zoe’s care and prevent this from happening again.”