Peterborough City Hospital urged to review policies following death of 86-year-old woman
The death of an 86-year-old woman has prompted calls for improved patient observation at Peterborough City Hospital.
The calls have been made by Coroner Simon Milburn following the death of Judith Hughes.
She was admitted to PCH on July 30 2020 following a tonic clonic seizure, where is was identified that she was suffering from fast ventricular atrial fibrillation and a high heart rate.
She also had a past history of significant heart disease.
Judith received treatment and was discharged on July 30, at which point there was no evidence that she was in cardiac failure.
Judith’s cardiac function declined from this point and she was further admitted to the hospital when there was clear evidence of worsening heart failure. Despite ongoing monitoring and care both in hospital and in the community, Judith died at her home in Park Road at just after midnight on October 7, 2020.
In a report, the coroner said that it was his opinion that ‘there is a risk that future deaths could occur unless action is taken.’
It added that: “The inquest heard evidence about the trust’s use of the ‘Close Observation Risk Assessment.’ This requires scores to be attributed to several factors including ‘inpatient falls during this admission’ and ‘previous falls’. The overlap between these two factors and what they actually refer to is unclear and confusing. This creates a risk that the overall score may be calculated incorrectly resulting in insufficient levels of observation, increased risk of falls and death.”
The North West Anglian NHS Foundation Trust has a duty to respond to the report by January 1, 2026.
Jo Bennis, Chief Nurse for North West Anglia NHS Foundation Trust, which runs Peterborough City Hospital, Hinchingbrooke Hospital & Stamford & Rutland Hospital said:
“The inquest concluded that Mrs Hughes died from natural causes and that a fall three months prior to her death did not in any way contribute to her death on 7 October 2020.
“The Regulation 28 report relates to a form which was in use at that time in relation to assessing the risk of a patient falling. The Trust will be responding to the Coroner formally in due course but we can confirm that the relevant form was amended in 2022 following a routine review.”