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Margaret Toye

Ref: 2022-0004 Date: 23 Dec 2021 Coroner: Graeme Irvine Area: East London 0 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted a failure to assess Mrs. Toye for malnutrition risk using the MUST score system, with an incorrect score recorded in her notes preventing further action. Audits revealed that one in ten patients on the ward were not being assessed for malnutrition risks.

Date 23 Dec 2021
56-day deadline 17 Feb 2022 stated in the report
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner noted a failure to assess Mrs. Toye for malnutrition risk using the MUST score system, with an incorrect score recorded in her notes preventing further action. Audits revealed that one in ten patients on the ward were not being assessed for malnutrition risks.
View full coroner's concerns
1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored Oon the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.

Report sections

Investigation and inquest
On the 22nd April 2021 I opened an investigation touching upon the death of Margaret Rose Toye, aged 81 years old. I opened an inquest on the 5th May 2021. The inquest concluded on the 21 st December 2021 . The conclusion of the inquest was Natural Causes, the record of inquest stated: "On the 10th April 2021 Mrs Margaret Rose Toye sustained an unwitnessed fall in the community and suffered a left neck of femur fracture. Following surgery to repair the fracture on 12th April 2021 Mrs Toye received ward based care and on 20th April she died following a cardiac arrest." The cause of death was recorded as; 1a Cardiac Failure 1 b lschaemic Heart Disease 1 c Coronary Artery Atherosclerosis II Fractured Left Neck of Femur
Circumstances of the death
Following a fall in the street on 10th April 2021 , Mrs Toye was taken by ambulance to hospital where she underwent a surgical repair of the fracture on 12th April 2021. Despite recovering from surgery well, whilst care for on the ward Mrs Toye sustained a cardiac arrest on 20th April 2021 . ·

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Report details

Reference
2022-0004
Date of report
23 December 2021
Coroner
Graeme Irvine
Coroner area
East London

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Feb 2022 (stated in the report).

Sent to

Department of Health and Social Care
Royal London Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.