Tamara Davis died in intensive care on December 13, 2022, of multiple organ failure and sepsis brought on by influenza, at the Royal Sussex County Hospital in Brighton.
At an inquest today in Horsham, area coroner Joanne Andrews concluded the 31-year-old’s death was of natural causes and that there was no evidence that being placed in the hospital corridor contributed to her death.
However the coroner expressed her “substantial concern” over the use of corridors and said she would be writing to the Department of Health and NHS England over the ongoing problem in a prevention of future deaths report.
The court heard Miss Davis, from Hollingdean, had been feeling unwell for several days and it was thought she had a bad cold.
She collapsed at her home and was admitted to the hospital at just after 11pm on December 10.
Miss Davis, who was coughing up blood, was put into the resuscitation area and given fluids, paracetamol and antibiotics after being diagnosed with a chest infection.
The court heard at 5.30am on December 11 she was wheeled out into the corridor of the “overwhelmed” department on a trolley where she would stay for ten hours. Miss Davis’s family disputes this, saying she was in the corridor for longer.
In a statement to the court, Miya Davis said her sister’s bed was put into the corridor while Miss Davis was in the toilet dealing with diarrhoea.
Miya said she asked a nurse to change a bedsheet on Miss Davis’s bed as it had been soiled by diarrhoea but said she was told she would have to change it herself.
The court heard Miss Davis improved slightly after her admission but throughout December 11 she deteriorated with “truly horrifying rapidity”.
She was given one dose of antibiotics, fluids and paracetamol during her treatment, and was moved out of the corridor to another cubicle at 3.20pm.
The inquest heard how her condition deteriorated and she was moved into intensive care later in the night on December 11 before she died on the morning of December 13.
Andrew Leonard, a consultant who treated Miss Davis on December 11, said he believed Miss Davis had the H1N1 flu strain, which in 2022 had caused the highest levels of hospital admissions since 2009.
He said he was “profoundly shocked” to later discover Miss Davis had been admitted to critical care when he started his shift the next day and that most people her age would not be hospitalised.
He said Miss Davis being in the corridor was “unacceptable” but there was “nowhere to put patients” and that this was a national issue.
“More corridor care has become the norm in the last few years,” he said.
“Anyone being looked after in a corridor is concerning as it’s a failure of normal care process.”
He added it was a response to “overwhelming pressure on the system”.
He said Miss Davis was “diagnosable” as being septic at 4.24pm on December 11 but she was not screened for the life-threatening condition until two hours later.
Dr Leonard said he was not sure it would have made “any material difference to the outcome” if she was diagnosed earlier.
“I have thought about this through many sleepless nights,” he said
“I do not think we could have predicted what would have happened to her.
“It’s a tragedy.”
Alice Edmondson, a senior sister at the hospital who was a shift leader during Miss Davis’s admission, said patients are treated in the corridors every day at the hospital.
“We would never move anyone to a corridor out of choice,” she said. “Nobody should be nursed in the corridor.
“I really want the family to know that I, as a senior nurse, I feel upset every day I go to work that people are in the corridor.
“We don’t have enough beds allocated on a regular basis to move our patients onto a ward.
“We have a continual flow of patients coming into the departments.
“Patients don’t get privacy.
“It’s overcrowded.
“People are too close to one another.”
It was heard the amount of people in the corridors reached up to 20 people on December 11.
Ms Edmondson saw Miss Davis in the corridor and spoke to nurses to get her moved back to resuscitation.
“I remember seeing her walk back to her trolley,” said Ms Edmondson.
“I remember thinking she was quite young for our usual patients.
“She looked small and frail.”
Kimberley O’Hara, divisional director of nursing in the medical division at the hospital, said the hospital is “full of patients who are medically ready to leave but have nowhere to go”.
Maggie Davies, chief nurse at University Hospitals Sussex NHS Foundation Trust, which runs the Royal Sussex, apologised to Miss Davis’s family.
“We wish to extend our heartfelt condolences to Miss Davis’s family and friends,” she said.
“We entirely accept that the experience Tamara, and her family, had in the ED corridor before admission to intensive care fell short of the standards our patients and families should expect – that is a matter of deep regret, and we are truly sorry.
“We also acknowledge the coroner’s concerns about the provision of corridor care, and we are committed to working with partners to continue to try to resolve this issue for patients and families.”
The trust said it has since taken actions to improve the flow through the hospital and increase capacity in the emergency department including working with partners to avoid admissions and by introducing a new in-hospital continuous flow model including a surgical assessment unit.
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