Royal Sussex County Hospital implements changes to staffing levels and communication after death of Heather Milton, an inquest has heard

Giving a narrative conclusion, assistant coroner for West Sussex, Brighton and Hove Joseph Turner said he had heard extensively from University Hospitals Sussex NHS Foundation Trust about remedial action taken since Heather’s death; notably in areas of communication and staffing levels.

Heather, 76, died as a result of a cardiac arrest after attending the A&E department of Princess Royal Hospital on Friday 16 December 2022 presenting with a two-day history of abdominal pain, the court heard.

The inquest was told that, approximately seven hours after arriving at the A&E department, Heather was transferred to the Royal Sussex County Hospital (RSCH) via ambulance.

On the morning of the 17 December 2022, Heather’s condition deteriorated, and she collapsed in cardiac arrest. Resuscitation was unsuccessful and Heather died 24hrs after arriving at A&E.

A post-mortem was deemed unnecessary by the hospital and a cause of death was given by the hospital as cardiac arrest secondary to hypovolaemic shock.

The coroner was told that a patient safety investigation was conducted which identified several failings including a delay in administration of the reversal of anticoagulants, communication issues and failure to recognise deterioration during admission to the emergency department. The Trust’s investigation identified a number of failings which have resulted in recommendations for improvement.

Recommendations from the serious incident report include:

• a "continuous flow" model to move patients out of the Emergency Department;
• a specific surgical assessment unit for patients with presentations like Heather;
• higher ratios of staffing;
• consultant to consultant discussion rather than involving junior doctors who might not have the experience needed to recognise a need for urgent referral;
• a phone line with a direct link to the transfusion lab;
• simulation training for junior doctors involving bleeding scenarios, 
• new guidance to deal with rectus sheath haematomas and updated protocols.

Heather’s husband of 49 years, Paul Milton said:

“Heather was the sort of person who would go into the shop for a loaf of bread and come out with a new friend. She was very sociable, and she related to people from all walks of life.

“I met Heather when I was in my twenties, and we were married five years later. We shared two sons and were due to celebrate our Golden Wedding Anniversary in October last year but, tragically, she was gone before we were able to do so.

“She was a keen sportswoman who loved badminton and tennis. She was also obsessed with Siamese cats and when she was alive, we had up to three at a time. I now only have one large very long-haired black cat as he is the last one left.

“My life as I knew it has gone. Life without Heather has been difficult and, at times it has been a struggle to see a future beyond my life with her. I know she would want me to be happy, so I have tried to find joy in new things since her death, but I will never forget her.”

Heather’s family is represented by Leigh Day medical negligence solicitor Frankie Rhodes and barrister Cressida Mawdesley-Thomas of 12 King’s Bench Walk.

Frankie said:

“It has been a privilege to have represented Paul Milton in this inquest and for probing questions to be asked of the witnesses being called from the Trust during this hearing. 

“It is the hope of Leigh Day, and Heather’s family that the outcome of this inquest ensures standards of care at Royal Sussex County Hospital are improved and the issues identified during the inquest, including unsafe levels of staffing, overcrowding and failures in communication are not repeated. Heather’s deterioration was not recognised or escalated to senior staff who might have intervened at an earlier stage to try and save her life. It is encouraging to hear of some recommendations for improvement which have been made within the Trust to improve outcomes.”