Evelyn Dutton

I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South

On 19 th August 2022 I commenced an investigation into the death of Evelyn Mary Dutton. The investigation concluded on the 4 th May 2023 and the conclusion was one of Narrative: Died from natural causes contributed to by complications of an accidental fall, poor nutritional status and complications of necessary medication. The medical cause of death was 1a) Multi-organ failure; 1b) Frailty; II) Multiple Duodenal Ulcers, Fracture left hip with Hemiarthroplasty, Poor Nutritional Status, Systemic Sclerosis

Evelyn Mary Dutton had severe Systemic Sclerosis. She was admitted to Stepping Hill Hospital following an accidental fall at her home address. It was identified that she had fractured her neck of femur. She was operated on. Post-operatively her weight was found to be low and she was referred to the dietetics team. Her nutritional status remained compromised and an Nasojejunal (NJ) tube was sited on 21 st July 2022. There was a delay in utilising the NJ Tube until 29 th July. The NJ feeding was subsequently stopped due to concerns of aspiration and fluid overload. It was restarted on the night of 4 th August. There was a significant electrolyte imbalance, probably due to refeeding syndrome due to the issues with nutrition. On 5 th August the feeding via the NJ Tube was stopped due to episodes of vomiting of blood from her gastro intestinal issues including duodenal ulcers, identified in a series of gastroscopies, probably caused by steroid treatment. She continued to become increasingly frail. She deteriorated further and died at Stepping Hill Hospital on 13 th August 2022.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. The inquest heard evidence that after her fall, on 28

th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day. Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29 th June when a bed became available;

1. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.