A coroner has filed a report to Health Secretary Wes Streeting over chair incident, which meant 91-year-old refused to go back to hospital and died from a blood clot
An elderly woman died after refusing to go to hospital because she had been left on a chair “for hours” on a previous visit despite having a broken back.
A coroner has filed a report to Health Secretary Wes Streeting over the incident which she put down to bed blocking and the NHS corridor care crisis. Dorothy Reid, 91, was “in discomfort for hours” in a busy emergency department at Queen Elizabeth the Queen Mother (QEQM) hospital in Margate, Kent, in March last year. When she needed emergency care again some days later she refused because she had “such a poor experience” previously.
Ms Reid died from a blood clot, but North East Kent Coroner Catherine Wood ruled that she may not have died when she did if she had attended A&E when advised.
Mrs Wood said: “On both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did.”
The news comes after NHS bosses warned that hospitals in England are “close to full” as a significant number of beds are occupied by people who are medically fit to be discharged. NHS England said last week that around 96% of hospital beds were full. And one in seven of these beds were taken by patients who were medically fit to be discharged.
It comes a month after the Mirror reported from the frontline of the NHS “corridor care” crisis which the Royal College of Nursing says is the worst it has ever been. Testimony from 5,000 nurses laid bare the consequences of a decade of NHS under-funding with patients spending hours slowly dying on trolleys in busy corridors and a dead patient being found under a pile of coats in a waiting room.
The Mirror reported on how a decade-long funding squeeze and lack of staff and ward space has meant the NHS has had to normalise corridor care. Before 2022 this kind of escalation was a temporary measure for extreme circumstances lasting usually 24 or 48 hours but now hospitals are expected to admit patients whether or not they have a free bed for them. It means wards have now expanded into corridors, toilets, cupboards, cloakroom and even car parks.
Mrs Wood has filed a Prevention of Future Deaths report to the Secretary of State and NHS England Chief Executive Amanda Pritchard, stating “action should be taken to prevent future deaths and I believe you have the power to take such action”. It highlighted how on both visits the A&E was busy but that “this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge”.
Ms Reid had been advised to go to hospital after suffering a fall at home. Spinal fractures were identified on an x-ray and she was referred to the emergency department where she was “kept overnight” before she was given an MRI. The report highlights how she “had to wait on a chair as there were no beds”.
During various interactions with health services in the aftermath of her experience, staff noted that she was suffering from breathlessness. Ten days after the first trip to A&E, her daughter contacted the 111 service and an ambulance was called after she was complaining of shortness of breath accompanied by swollen feet and lower legs. The report states: “Although the ambulance crew advised that she should attend hospital, she wanted to avoid a trip to hospital due to her previously having to wait in discomfort for hours.”
A few days later Ms Reid was taken to A&E where she died. Her cause of death was recorded as a blood clot which developed during her reduced mobility because of the fall. The fall also caused spinal fractures due, in part, to underlying osteoporosis. But Mrs Wood said that if Ms Reid had gone to A&E a second time she may not have died when she did.
Mrs Wood said: “The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into.
“This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem. This, in conjunction with the reluctance of patients to attend the emergency department due to long waiting times clearly gives rise to a risk of future deaths unless something is done.”
A spokesperson from the Department of Health and Social Care said: “Our deepest sympathies are with Dorothy’s family and friends. This Government inherited a broken NHS and far too many patients are facing unacceptable waits for treatment. We are determined to turn the NHS around through our plan for change so it can be there for everyone when they need it.
“We have taken action over the past six months to protect A&E departments – rolling out the new RSV vaccine, vaccinating more people against flu, and ending resident doctor strikes. We will tackle delayed discharges by improving links between the NHS and social care, shifting the focus of care from hospital to community.”
A spokesperson for East Kent Hospitals, which runs the hospital, said: “We are sorry Dorothy had such a difficult experience in our emergency department last March, which falls way below the standard we want for our patients. We extend our condolences to Dorothy’s family.”