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Senior coroner raises concerns over hospital care of patient who died unexpectedly

PUBLISHED: 15:45 03 July 2018 | UPDATED: 15:46 03 July 2018

Kirsty Tolley, 28, died at the Queen Elizabeth Hospital in King's Lynn on February 19, 2017. Picture: Sue Tolley

Kirsty Tolley, 28, died at the Queen Elizabeth Hospital in King's Lynn on February 19, 2017. Picture: Sue Tolley

Sue Tolley

Norfolk’s senior coroner has raised concerns over the quality of care given to a young woman before she died suddenly in hospital.

Jacqueline Lake has handed her report to the Queen Elizabeth Hospital (QEH) in King’s Lynn following an inquest into the death of 28-year-old Kirsty Tolley.

In response the hospital said it was bringing in a new national early warning system six months earlier than required by the NHS.

Miss Tolley, from Walsoken, died at the QEH on February 19, 2017, nine days after she was admitted. The cause of death was recorded as unascertained.

An inquest at King’s Lynn Coroner’s Court on Friday, May 4, heard Miss Tolley was admitted to the hospital on February 10 with a low haemaglobin level.

She was started on an iron infusion treatment called Ferinject and plans were put in place for daily blood tests to be carried out.

But despite being seen by a number of specialists she was found unresponsive in her bed on February 19.

Upon hearing all the evidence, the senior coroner recorded an open conclusion at the end of the inquest.

Ms Lake said in her report that the hospital did not carry out daily blood tests.

She said the inconsistent blood tests “meant there is a vacuum of evidence with regard to the medical cause of death.”

She said early warning scores (EWS), which determines the degree of illness of a patient, were to be assessed and recorded three times a day, but this was not done on February 11 and February 17.

Evidence was heard that if the EWS had risen to three then this should be escalated to a doctor who should review the patient and set a plan.

But in Miss Tolley’s case, her EWS reached three on four occasions and there was no evidence that any additional action was taken.

The hospital’s medical director Dr Nick Lyons said: “We are a learning organisation and have robust processes and governance in place to ensure we do learn at every opportunity.

“An example of this being that the Trust has decided to bring forward plans to adopt the National Early Warning System (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1, 2018.”


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