Tracey Farndon, a 56-year-old mother and grandmother, tragically died only hours after her arrival at Queen Elizabeth Hospital in Birmingham due to a failure to properly identify and escalate signs of sepsis. The inquest into her death found significant failures and missed opportunities at the hospital. Tracey had sought help at the A&E department after feeling unwell for three days. However, basic tests, such as a blood pressure reading, were not conducted, and the significance of her condition was not detected by medical staff.
During the seven hours Tracey spent in A&E, she was not given a full assessment, and her deteriorating condition was not recognized. She went into cardiac arrest and died that morning. The coroner determined that gross failings at the hospital contributed to Tracey’s death, which was attributed to natural causes. Tracey’s post-mortem revealed that septic shock, developed from pneumonia, likely caused her death. The delay in treatment escalation and failures to appropriately measure and record her blood pressure were identified as gross failures amounting to neglect.
Following the inquest, Tracey’s family expressed a sense of justice, as the coroner highlighted the deficiencies in the hospital’s emergency department. Her daughter, Jess Sulmina, who was pregnant when her mother died, emphasized the lack of care Tracey received when she needed it most. The coroner emphasized that proper care could have saved or prolonged Tracey’s life, and there was a genuine lack of understanding about sepsis at the hospital. Measures were being taken to improve hospital staffing issues to prevent similar incidents in the future.
Jess Sulmina stated that the memories that could have been made with her mother were lost due to the tragic circumstances. She expressed hope that lessons would be learned from Tracey’s death to prevent other families from experiencing such devastating loss. The University Hospitals Birmingham NHS Foundation Trust issued apologies for their failings, and two Prevention of Future Death reports will be issued to highlight the need for improvements in hospital staffing. The coroner concluded that Tracey’s death was contributed to by neglect, and proper care could have made a difference in the outcome.
