Improvements have been made at Buckinghamshire Healthcare NHS Trust following the death of a 28-year-old student nurse on Christmas Eve 2022.
Zoe Bell, from High Wycombe, died on 24 December 2022 from a complex lung infection, which included sepsis, pneumonia and influenza, 20 hours after she arrived at Stoke Mandeville Hospital.
“Improvements to our emergency care pathways have included increasing staffing”
Andrew McLaren
Before her death, Ms Bell had spent 12 hours in the A&E department waiting for a clinical assessment, an inquest into Ms Bell’s death held last year was told.
Senior coroner for Buckinghamshire Crispin Butler concluded that Ms Bell died from natural causes, but he said that the hospital had some “learning” to do.
The coroner decided not to publish a formal Prevention of Future Deaths Report but has now sent a letter to the trust outlining some areas of concern that were raised in the inquest.
Mr Butler wrote that it was clear from evidence given at the inquest that there had already been “change” within the trust, “in part through inevitable locally changing practice, in part through more national changes, but also in part specifically through the investigation of Zoe’s death”.
He added that if these changes had not been introduced, he would be “concerned” about “potential problems” manifesting in the future.
Some of the changes he highlighted included improvements in observations, since Ms Bell’s case identified shortcomings in carrying out or recording regular observations. This has been addressed by the presence of a healthcare assistant in the A&E waiting room to take regular observations, and improved staffing levels from 18 to 22 per shift.
He also welcomed the introduction of a sepsis screening tool, and the opening of an urgent treatment centre to improve triaging and prioritisation.
He also cited improved awareness and signage about the CURB-65 tool for assessing pneumonia severity, and the use of digital technology to improve the accuracy of records and to address IT access issues.
Mr Butler also welcomed a reduction in the use of agency staff and irregular locum doctors.
Chief medical officer of Buckinghamshire Healthcare NHS Trust Andrew McLaren said: “On behalf of the trust I would like to express my heartfelt personal condolences to Zoe’s family, friends, and colleagues for their tragic loss.”
Mr McLaren said the trust was “grateful” for the detailed investigation conducted by the coroner which had identified a number of learning points, which the trust had taken on board and had been addressing.
“It is noted that the coroner concluded that, sadly, there was not an opportunity to provide any care following Zoe’s admission to hospital which would have avoided her decline, and she died of natural causes from a rare combination of infections,” Mr McLaren said.
“Improvements to our emergency care pathways have included increasing staffing, extending the hours of the urgent treatment centre and last month we opened an additional medical ward,” Mr McLaren added.
