Pensioner died after 'neglect during junior doctors' strike'

A 71-year-old stroke patient suffered neglect during the junior doctors strike which "contributed to her death" a coroner has ruled - and he's warned of more deaths in the future unless action is taken.

Diabetic Daphne Austin was admitted to the Cumberland Infirmary in Carlisle on 22 May 2023 following a stroke.

While in hospital, she became dehydrated and by 14 June had sustained an acute kidney injury.

However, she had no blood tests on 15 or 16 June when junior doctors were taking industrial action and her fluid balance was poorly monitored - factors, the coroner said,, which contributed to her death from sepsis on 18 June.

The report said: "Whilst in hospital, Ms Austin's glucose levels were poorly controlled. She also became dehydrated. Ms Austin's fluid balance was not monitored in an effective manner."

A Prevention of Future Deaths report, written by assistant coroner for Cumbria, Robert Cohen, said: "In my opinion there is a risk that future deaths will occur unless action is taken".

It went on: "There was evidence from one of the Trust’s consultants that on the day of the strike she had to 'look after nearly 25 patients' and that 'due to the junior doctor’s strike on 14/06/2023, Mrs Austin did not receive any medical input that day'.

"Another consultant gave evidence that despite being listed as one of the consultants covering the unit (in the contingency planning evidence) he was probably dealing with other duties on that day.

"In the circumstances I am concerned that the planning that seeks to ensure safe levels of cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths."

The report has been sent to the North Cumbria Integrated Care NHS which has 56 days to respond to it.

North Cumbria NHS Trust said: "We offer our sincere condolences to the family and friends of Mrs Austin. Our initial findings indicate that some opportunities were missed to improve the care delivered to Mrs Austin.

"We have worked with the clinical team to improve the way that fluid intake is monitored and this has been acknowledged by the Coroner in their ruling. We are now reviewing the full findings to consider what other lessons can be learned.

“During any period of industrial action we do put plans in place to cover any shortages in staffing. We are sorry the Coroner felt this was a factor on this occasion."

In response to the Prevention of Future Deaths Report from Cumbria coroner Robert Cohen, Professor Philip Banfield, Chair of the BMA Council, said: "We are really sorry this happened.

"Our heartfelt condolences go out to Daphne Austin’s family; this is a death that could well have been avoided. As the Coroner notes, the North Cumbria Trust’s lack of preparation and inability to ensure sufficient staffing levels during industrial action significantly contributed to this woman’s death.

"This is exactly why, throughout the strike action, the BMA consistently urged NHS England to prioritise patient safety and ensure proper planning across hospital trusts.

“Throughout all strike periods, the BMA made it clear that during any action taken by members, Trusts must maintain safe and appropriate staffing levels to ensure patient safety. Cover across England was provided often by more senior doctors – consultants, associate specialist doctors and specialty doctors as well as specialists.

“This Trust, which received a warning notice from the CQC following inspections in August and September 2020 to make immediate improvements for patient safety has a longstanding history of issues related to patient safety and staffing levels, with multiple overall CQC ratings of 'requires improvement'.

“We hope the new government will take patient safety as seriously as doctors do and see this avoidable death as a stark warning.

"Our health service needs to be properly staffed and resourced, not just during industrial action but always, as we know there are avoidable deaths and patients coming to harm in hospitals every day, because of consistent understaffing, poor planning and poor management of resources.”

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