A FITNESS instructor died in her husband’s arms from a “pain-induced” cardiac arrest having been discharged from A&E just hours earlier.
Winifred Sharon Lamb, known as Sharon, died at her home in Wylam, Northumberland, in the early hours of May 19, 2022, at the age of 63.
NJC MediaA coroner’s court ruled there had been ‘missed opportunities’ by the the Royal Victoria Infirmary[/caption]
She had been discharged from the Royal Victoria Infirmary (RVI) in Newcastle just 11 hours earlier without staff witnessing whether she could walk or put weight on her hip.
Following the conclusion of an inquest into her death, Sharon’s son, Matthew, 38, said: “The family have tried throughout to engage with the RVI hospital in a spirit of openness and candour, to help the trust find out what happened from the time that Sharon was admitted by ambulance because she was in severe pain from her hip; to being discharged five hours later still in pain and without any treatment being offered.
“We have been through a long a tortuous process during which the trust have not accepted our concerns.
“It has taken the coroner to point out to the trust that from the initial triage on Sharon’s admission, through to discharge, Sharon’s care was mismanaged with inadequate assessments and missed opportunities to give appropriate treatment and care, culminating in an inappropriate discharge.”
He added: “Tragically, Sharon died just 10 hours later due to the pain. This is an absolute tragedy for Sharon and all her family and friends, which could easily have been avoided and the unwillingness of the trust to understand and act on our concerns has only aggravated the distress and upset we have all suffered.”
The inquest heard that paramedics had arrived at her home at 11.42am on May 18, 2022 and discovered Sharon crying on the sofa due to the chronic pain in her right hip.
Sharon had previously been diagnosed with osteoarthritis in her right hip and had been given morphine for the pain.
An ambulance took her to the RVI, arriving at 1pm and paramedics provided a handover detailing Sharon’s case, including her latest pain score of seven which was recorded at 12.56pm.
She was put into the care of the RVI emergency care department, with staff deciding her condition fell into category four at triage – the lowest severity rating given to patients at the hospital.
Coroner Andrew Hetherington concluded that this was an under-triage in Sharon’s case by at least one category.
He also found that there were “missed opportunities for assessment at hospital,” a Chronicle report says.
The Coroner’s Court heard Sharon did not get a nursing assessment until four hours after her arrival to the emergency department, well outside of the recommended 15 to 30 minutes of arrival to the hospital.
In addition, hospital staff recorded a pain score of four in their assessments and did not refer back to the notes made by the paramedics.
The inquest heard that checking the records provide by paramedics was not standard practice.
It was also told that no staff at the hospital had witnessed Sharon walk on her own before she was discharged and did not receive a mobility assessment.
Junior doctor Nicola Richards, who cared for Sharon in emergency care, told the inquest she had “surmised” Sharon had moved herself from the trolley she was lying on to a commode and back without assistance, which would require four to five steps.
She said she had come back to the room and was “surprised” that Sharon had used the commode.
Sharon was allowed to go back home later that day and her husband, David Lamb, told the court he found his wife at in a wheelchair at the entrance alone, adding that she “looked dreadful”.
Coroner Hetherington referred back to David’s statement, which said: “I wheeled Sharon to the car which was parked in the car park outside.
“I helped her into the car with some difficulty, she was unable to put any weight on her right side and was generally in a lot of pain from her right hip which was radiating out.
“As soon as I got her into the car I had to recline the car seat back as far as I could because Sharon could not sit and yet she had been put in a wheelchair to discharge her.
“I had to drive very slowly to get back home and went via Kingston Park Boots Pharmacy to get the prescription.”
Paramedics were called back to their home in the early hours of May 19 where Sharon suffered a pain-induced cardiac arrest.
Coroner Hetherington said, in reference to the evidence provided by the paramedics: “On May 19, 2022, at approximately 03.49 paramedics were assigned a call to attend a female adult in cardiac arrest.
“Paramedics arrived at the home address at 03.58. Mr Lamb was performing chest compressions, paramedics applied the defibrillator and Sharon was seen to be in ventricular fibrillation.”
Concluding, Coroner Hetherington said Sharon died from “natural causes, to which there was an inadequate triage and missed opportunities for assessment at hospital.”
He added it is not possible to say whether Sharon would have survived if she had been admitted to hospital.
A spokesperson for Newcastle NHS Foundation Trust said: “We are very sorry there were missed opportunities during the triage and assessment of Mrs Lamb in the Emergency Department and offer our heartfelt condolences to all of her family.
“We are treating this feedback very seriously and will undertake further work in response to the concerns raised by the coroner.”
NJC MediaSharon suffered a pain-induced cardiac arrest[/caption]
NJC MediaAn ambulance had taken Sharon to the Royal Victoria Infirmary on May 18, 2022[/caption]