Margaret Grimsley

I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin.

On 3 February 2025 I commenced an investigation into the death of Margaret Elizabeth GRIMSLEY The investigation concluded at the end of the inquest on 6 January 2026 The conclusion of the inquest was a natural cause being Ia) frailty and advanced chronic obstructive pulmonary disease II) right sided heart failure

Margaret Elizabeth Grimsley was admitted to the Royal Shrewsbury Hospital on the 16 December  2024 following a fall at home. Mrs Grimsley had comorbidities and was seriously ill. Sadly, she did  not recover and following an infection in the last 24 to 48 hours of her life, she died while still at the hospital on the 22 January 2025.

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 apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations as and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. (2) The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. (3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so.

In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.