Sarah Hill

I am Margaret Taylor HM Assistant Coroner for Cumbria

On 12 November 2024 I commenced an investigation into the death of Sarah Kathleen HILL.  The investigation concluded at the end of the inquest on 13 May 2025 . The conclusion of the inquest was a narrative conclusion that Sarah Hill Died as a consequence of the recognised complications of a necessary medical procedure . I found that her cause of death was: 1a Systemic Inflammatory Response Syndrome 1b Common bile duct perforation and Pancreatitis 1c Gallstones II Coronary Artery Atherosclerosis

CIRCUMSTANCES Mrs Hill was a 78 year old lady who was admitted to the Cumberland Infirmary on 5 November 2024 for an elective ERCP procedure for the removal of gallstones .Small stones  and fragments were successfully removed during the ERCP but the largest stone could not be removed as it was impacted at the level of sphincterotomy . A stent was inserted to enable bile duct patency and the procedure abandoned . Mrs Hill complained of nausea , vomiting  and pain post procedure . Approximately seven hours later a CT scan and bloods were  ordered to rule out any significant pathology . A decision was made to admit her due to  pancreatitis which is a recognised complication of ERCP . The CT did not show evidence of  perforation . On 6 November blood results revealed an increase in amylase and Mrs Hill  developed a temperature suggesting her pancreatitis was worsening . On 7 November she  became tachycardic and short of breath . She collapsed whilst going to the toilet . A further CT scan demonstrated a significant worsening of the pancreatitis , a new acute collection , air in the retroperitoneum , ascites and a new pleural effusion . She was referred to the surgical  team who decided she was not for escalation . At approximately 17.00 hours she had an  unwitnessed fall at a time when she was meant to be closely observed . She was helped to a  chair and whilst observations were attempted she became unresponsive . At 17.54 hours she went into cardiac arrest . Blood results demonstrated multi organ failure . Her prognosis was  poor due to the response to pancreatitis and perforation . A DNACPR was agreed and a plan  made for end of life care . Mrs Hill died in the early hours of 8 November 2024 .

During the course of the inquest the evidence revealed matters giving rise to concern about  the standard of nursing care provided to Mrs Hill. 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) There was a lack of evidence suggested appropriate falls risk assessments had been  undertaken and a failure to report falls / collapses on the ward . (2) There was a lack of documentation about the use of cot sides and the placement of the  call bell within Mrs Hill’s reach . (3) There was a lack of frequent recorded observations necessitated by Mrs Hill’s deteriorating condition. (4) Mrs Hill was placed in a side room where she was not easily observed without  consideration given for the need for additional monitoring which led to her being left alone for  extended periods of time. (5) I was advised that the ward was understaffed and under pressure .I was told that despite  this being appropriately escalated nurses were caring for 10 patients when the expected  allocation would be 6 patients for each nurse on duty .No further help was provided to the  ward following escalation . The evidence presented to me was that this was not an unusual  situation on the ward .

In my opinion action should be taken to prevent future deaths and I believe you North  Cumbria Integrated Care NHS Trust have the power to take such action.