Inquest finds Mum died aged 56 of natural causes contributed to by neglect and delay in sepsis diagnosis

Senior Coroner Louise Hunt concluded that Tracey died of natural causes contributed to by neglect and delayed diagnosis.

Ms Hunt outlined the ‘gross failings’ that more than minimally contributed to Tracey’s death, and stated that she will write two Prevention of Future Death (PFD) reports following the inquest: one to the Department of Health and Social Care; and one to University Hospitals Birmingham NHS Foundation Trust to highlight how hospital staffing issues must be improved.
 
Tracey, of Birmingham, died on 25 April 2023 following a failure to properly identify and escalate signs of sepsis on admission to the emergency department at Queen Elizabeth Hospital, Birmingham, which delayed necessary treatment from taking place. 
 
Had proper early intervention by medical staff occurred, Tracey would not have gone into cardiac arrest and died that morning, said Ms Hunt at the inquest at Birmingham and Solihull Coroners Court on Thursday 3 April 2024.
 
Having previously been fit and healthy, Tracey arrived at the emergency department in the early hours of 25 April after feeling unwell for three days, experiencing vomiting, fatigue, worsening pain in her back and legs, and diarrhoea.  
 
The emergency department was particularly busy that night and was understaffed.  
 
Basic tests were not sufficiently conducted, for instance, a blood pressure reading was not obtained. The significance of this was not detected by medical staff as Tracey’s blood pressure was likely to have been too low for a reading to be picked up by the machine. However, this was not investigated nor escalated by the staff. It is likely that Tracey’s blood pressure reading would have resulted in a National Early Warning Score (NEWS2) of 2 to 3. This would have led to escalation of care. It would have included blood tests, which would have detected developing sepsis. Tracey’s care would have been escalated to a Sepsis 6 treatment pathway.  
 
During the seven hours that Tracey was in the emergency department, she was not given a full assessment and was only assessed from a pain and medication perspective.  
 
Repeated observations should have happened frequently, as Tracey was deteriorating and was severely dehydrated, which was not detected.  
 
Tracey went into cardiac arrest and died that morning. Her partner Tom Parkin and daughter Jess Sulmina were with her when she died.  
 
The post-mortem examination report revealed that cause of death was likely septic shock, which developed from pneumonia. 


Ms Hunt found that the contributing factor to Tracey’s cardiac arrest and subsequent death that morning was the delay in treatment escalation. The failures to appropriately (1) measure and record her blood pressure on arrival and (2) calculate the NEWS2 score were gross failures amounting to neglect. These failures contributed to Tracey’s death.
 
A lack of staffing was also highlighted in the inquest as an ongoing issue, and witnesses from the hospital said that measures are being taken to ensure that this improves.  
 
Apologies were given in the inquest on behalf of University Hospitals Birmingham NHS Foundation Trust for the failings. 
 
Ms Hunt concluded that proper care could have saved or prolonged Tracey’s life. She said that “it wasn’t appreciated [by the hospital staff] that she was suffering from sepsis”, and she acknowledged the importance of the Trust identifying their failures.
 
Jess Sulmina said:
 
“I am relieved by the Coroner’s decision today and that I can finally feel a sense of justice following this shocking and devastating tragedy. I am glad that the University Hospitals Birmingham NHS Foundation Trust has had to give answers for what happened the day my mother died and that there is a clear account of the deficiencies in the Emergency Department. 
  
“What my mother went through in the final hours of her life was truly horrendous and I am completely heartbroken about the lack of care she experienced when she needed it most. I am glad that the Coroner has recognised the seriousness of what happened given that she concluded that my mother’s death was contributed to by gross failures amounting to neglect. 
  
“I am still processing the whole tragedy, and the feelings of anger and disbelief are still with me to this day. Before I knew it, she was gone; I never got the chance to say goodbye. 
  
“I was pregnant at the time, and it is gut-wrenching to think about the memories that could have been made with my mother had things turned out differently. 
  
“I am reassured by the Coroner’s decision to issue two Prevention of Future Deaths Reports, one to the Department of Health and Social Care and one to the Trust. I sincerely hope that lessons are learned so that no other family has to go through what we’ve been through. 
 
“I am grateful to our barrister, Anthony Searle, and Sanja Strkljevic at Leigh Day for their help in achieving this outcome.”
 
Leigh Day associate solicitor Ella Cornish, who represented Jess and Tracey’s family alongside clinical negligence partner Sanja Strkljevic, said:

“The evidence at the Inquest has today recognised the substantial failings in the care that was provided to Tracey. It has been very distressing for Tracey’s family to hear that her life could have been prolonged if the proper care had been provided to her when she attended Queen Elizabeth Hospital. Sepsis is a medical emergency and there are clear national and local guidelines to ensure that it is recognised and treated effectively before it becomes life-threatening. Unfortunately, as the evidence has shown today, these guidelines were not followed when Tracey attended the Emergency Department.  
   
“I am pleased that the Coroner has recognised the seriousness of the failings in Tracey’s care and has issued a Prevention of Future Deaths report to the Trust and to the Department of Health and Social Care. I hope that effective changes will be implemented to ensure no further lives are lost as a result of poor emergency care.”