Margaret Pilgrim

I am SONIA HAYES, area coroner, for the coroner area of ESSEX

On 7 July 2023 I commenced an investigation into the death of Margaret Ann PILGRIM, AGE 88. The investigation concluded at the end of the inquest on 5 June 2024. The conclusion of the inquest was 1a Congestive Cardiac Failure and Bronchopneumonia, 2 Frailty, Fall with a Fractured Clavicle Natural Causes contributed to by a Fractured Clavicle

Margaret Ann Pilgrim died of Congestive Cardiac Failure and Bronchopneumonia at the Princess Alexandra Hospital on 29 June 2023 in a background of frailty. Mrs Pilgrim sustained a fractured clavicle in an unwitnessed fall at home on 3 June 2023 and was discharged from hospital on 4 June. Mrs Pilgrim’s fractured clavicle was not on her discharge summary and her GP prescribed analgesia on 6 June. Mrs Pilgrim declined rapidly on 10 June with delirium and again on 16 June and had been treated with antibiotics. A scan on 19 June showed no evidence of pneumonia or malignancy and Mrs Pilgrim remained unwell and further tests were completed. Mrs Pilgrim was admitted into hospital and despite treatment continued to decline with intermittent delirium. Mrs Pilgrim was placed on end-of-life care.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.

In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.