16 January 2024 , 09:54
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An "active and fit" fitness instructor died from a pain-induced cardiac arrest hours after being discharged from A&E with hip pain.
Winifred Sharon Lamb, known as Sharon, died at her home in Wylam in the early hours of May 19, 2022, aged 63. She had been discharged from Newcastle's Royal Victoria Infirmary (RVI) less than 11 hours before her death, without staff witnessing whether she could walk or put weight on her hip.
Speaking after the conclusion of Sharon's inquest, her son, Matthew Lamb, said: "The family have tried throughout to engage with the RVI hospital in a spirit of openness and candour, to help the trust find out what happened from the time that Sharon was admitted by ambulance because she was in severe pain from her hip; to being discharged five hours later still in pain and without any treatment being offered.
"We have been through a long a tortuous process during which the trust have not accepted our concerns. It has taken the coroner to point out to the trust that from the initial triage on Sharon's admission, through to discharge, Sharon's care was mismanaged with inadequate assessments and missed opportunities to give appropriate treatment and care, culminating in an inappropriate discharge."
Matthew, 38, added: "Tragically, Sharon died just 10 hours later due to the pain. This is an absolute tragedy for Sharon and all her family and friends, which could easily have been avoided and the unwillingness of the trust to understand and act on our concerns has only aggravated the distress and upset we have all suffered."
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An inquest into Sharon's death heard that paramedics arrived at her home at 11.42am on May 18, 2022, and found Sharon crying on the sofa due to chronic pain in her right hip. The grandmother, who had previously been diagnosed with osteoarthritis in her right hip, was deemed to have a pain score of nine out of 10 and was given morphine for the pain.
At 1pm she arrived at the RVI via ambulance and paramedics provided a handover detailing Sharon's case, including her latest pain score of seven which was recorded at 12.56pm. She was placed into the care of the RVI emergency care department, where staff decided her condition fell into category four at triage - the lowest severity rating given to patients at the RVI.
Coroner Andrew Hetherington concluded that this was an under-triage in Sharon's case by at least one category. He also found that there were "missed opportunities for assessment at hospital".
Northumberland Coroner's Court heard that Sharon did not receive a nursing assessment until four hours after her arrival to the emergency department, which was well outside of the recommended 15 to 30 minutes of arrival to the hospital. Furthermore, hospital staff recorded a pain score of four in their assessments and did not refer back to notes provided by paramedics, which indicated that Sharon was in far greater pain. However, the inquest heard that checking the record provided by paramedics was not standard practice.
The court also heard that no staff at the hospital witnessed Sharon walk on her own before she was discharged from the hospital and she did not receive a mobility assessment. Dr Nicola Richards, a junior doctor who cared for Sharon in emergency care, told the inquest that she "surmised" that Sharon had moved herself from the trolley she was lying on to a commode and back without assistance, which would require four to five steps. She said she had come back to the room and was "surprised" that Sharon had used the commode.
Sharon was allowed to return home later that day and the court heard that her husband, David Lamb, found his wife waiting at the entrance in a wheelchair alone when he went to collect her and she "looked dreadful".
Coroner Hetherington referred back to David's statement, which read: "I wheeled Sharon to the car which was parked in the car park outside. I helped her into the car with some difficulty, she was unable to put any weight on her right side and was generally in a lot of pain from her right hip which was radiating out.
"As soon as I got her into the car I had to recline the car seat back as far as I could because Sharon could not sit and yet she had been put in a wheelchair to discharge her. I had to drive very slowly to get back home and went via Kingston Park Boots Pharmacy to get the prescription."
Paramedics were called back to Sharon's home in the early hours of May 19 where Sharon suffered a pain-induced cardiac arrest. Her time of death was recorded as 4.52am.
Referring to evidence from paramedics, Coroner Hetherington said: "On May 19, 2022, at approximately 03.49 paramedics were assigned a call to attend a female adult in cardiac arrest. Paramedics arrived at the home address at 03.58. Mr Lamb was performing chest compressions, paramedics applied the defibrillator and Sharon was seen to be in ventricular fibrillation."
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Paramedics attempted resuscitation for 30 minutes but Sharon sadly passed away.
Coroner Hetherington concluded that Sharon died from "natural causes, to which there was an inadequate triage and missed opportunities for assessment at hospital." He added that it is not possible to say whether Sharon would have survived if she had been admitted to hospital. The inquest had previously heard that survival rates of a cardiac arrest are low in and outside of hospital.
A spokesperson for Newcastle NHS Foundation Trust said: "We are very sorry there were missed opportunities during the triage and assessment of Mrs Lamb in the Emergency Department and offer our heartfelt condolences to all of her family. We are treating this feedback very seriously and will undertake further work in response to the concerns raised by the coroner."