Source · Prevention of Future Deaths
Frances Bell
Ref: 2014-0299
Date: 6 Jun 2014
Coroner: Caroline Beasley-Murray
Area: Essex
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted the absence of a Root Cause Analysis investigation, a lack of input from senior clinical staff at the time of presentation, and an unacceptable delay between readmission and arrival in theatre.
Date
6 Jun 2014
56-day deadline
1 Aug 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted the absence of a Root Cause Analysis investigation, a lack of input from senior clinical staff at the time of presentation, and an unacceptable delay between readmission and arrival in theatre.
View full coroner's concerns
(1) There was no Root Causes Analysis Investigation carried out which would have identified lessons learned and an action plan (2) There was no input from senior clinical staff at the time of Mrs Bell’s presentation on 30 March (3) There was an unacceptable delay between Mrs Bell’s readmission on the 31 March and her arrival in theatre on 1 April
Report sections
Investigation and inquest
On 18 April 2012 Dr Peter Dean the former Southend Coroner commenced an investigation into the death of Frances Margaret Ann Bell. The investigation concluded by me at the end of the inquest on 6 March 2014. The conclusion of the inquest was a narrative verdict:-
In the evening of 30 March 2012, Frances Margaret Ann Bell presented at Southend Hospital and she was discharged just after midnight. She was readmitted the next day and on 1 April she underwent abdominal surgery. She died on 13 April 2012. There were very serious failings in the care Mrs Bell received in Southend Hospital. With timely, appropriate care Mrs Bell might have survived. The medical cause of death was :-
1a) bowel ischaemia b) internal herniation
11) abdominal adhesions
In the evening of 30 March 2012, Frances Margaret Ann Bell presented at Southend Hospital and she was discharged just after midnight. She was readmitted the next day and on 1 April she underwent abdominal surgery. She died on 13 April 2012. There were very serious failings in the care Mrs Bell received in Southend Hospital. With timely, appropriate care Mrs Bell might have survived. The medical cause of death was :-
1a) bowel ischaemia b) internal herniation
11) abdominal adhesions
Circumstances of the death
On 30 March 2012 Mrs Bell presented at Southend Hospital with abdominal pain and she was discharged at just after midnight On 31 March Mrs Bell was readmitted and she underwent surgery on 1 April There were very serious failings in the care Mrs Bell received in Southend Hospital
Copies sent to
Care Quality Commission
Similar PFD reports
Report details
- Reference
- 2014-0299
- Date of report
- 6 June 2014
- Coroner
- Caroline Beasley-Murray
- Coroner area
- Essex
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Aug 2014 (stated in the report).
Sent to
- Southend Hospital