The death of a healthy woman waiting at an overcrowded A&E could have been avoided, a coroner has ruled. Norma Campbell, 59, had no underlying chronic diseases when she presented with sepsis to Whipps Cross Hospital in East London on January 13 2024, but waiting times, delays in treatment, and failures to monitor her properly ended with a deadly cardiac arrest nine hours after admission.
On the night of Norma’s death, the coroner also found there were more than 25 patients in the corridors, not receiving an appropriate level of care.
The inquest heard patient numbers and a lack of locum doctors, due to a pay dispute with the Trust, meant prompt and necessary sepsis care in line with national guidelines was not provided. Not only were there no resuscitation beds, but there we also delays in administering three types of antibiotics and a failure to properly monitor Norma’s fluids.
Had her abnormal lactate levels been properly monitored she may have received different level of care, the inquest heard. Sadly after she went into cardiac arrest, efforts to revive her were unsuccessful and she died in the early hours of January 14.
East London Area Coroner Nadia Persaud wrote: “Campbell presented to the emergency department with clear signs of sepsis. Sepsis was recognised very early in her presentation, but the prompt and necessary sepsis care set out in the NICE guidelines was not provided . On the balance of probabilities, had Mrs. Campbell received [a compliant] level of care, her death would have been avoided.”
In a prevention of future deaths report, Ms Persaud said overcrowding in A&E is a national concern, and that Whipps Cross Hospital ‘often’ has inadequate staffing and medical facilities to address patient numbers.
An insufficient number of resuscitation beds, a lack of electronic observation system, and the absence of the critical care outreach team for deteriorating patients were also highlighted as issues in the report.
A spokesperson for Barts Health NHS Trust said: “We offer our heartfelt condolences to Mrs Campbell’s family and loved ones during this very difficult time. We are carefully reviewing the coroner’s report and will provide a full response by August 2025, setting out the steps we are taking to learn from this and improve patient care.”
Symptoms of sepsis
Sepsis is life threatening. It can be hard to spot.
There are lots of possible symptoms. They can be like symptoms of other conditions, including flu or a chest infection. However, some signs in an adult or older child:
- acting confused, slurred speech or not making sense
- blue, grey, pale or blotchy skin, lips or tongue – on brown or black skin, this may be easier to see on the palms of the hands or soles of the feet
- a rash that does not fade when you roll a glass over it, the same as meningitis
- difficulty breathing, breathlessness or breathing very fast
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