“On 29.10.25 Mrs”

The coroner’s concerns

On 29.10.25 Mrs. O'Brien's Liver Function Test ( LFT ) results had been abnormally high ( Gamma GT: 545, ALT: 200 ). The plan was to repeat those tests a few days later. At around 2300hrs on the night of 2.11.25 Mrs. O'Brien was transferred to the Pathway to Discharge Unit ( PDU ) at Worcestershire Royal Hospital with a view to her discharge for further rehabilitation to Pershore Community Hospital. At the time of her transfer to the PDU, it was recorded in her notes that she had been experiencing gastrointestinal pain for the previous hour, and had passed loose stools. Her LFTs were repeated that morning, and although had lowered, were still considered abnormally high ( Gamma GT: 387; ALT: 122 ). At 1200hrs on 3.11.25 a trauma and orthopaedic doctor recorded that Mrs. O'Brien's discharge could not go ahead because of these still abnormal LFT results. The note continues: "Escalated the problem to the capacity team, and they instructed that the discharge will proceed.” At 1230hrs it is recorded that Mrs. O'Brien was re-assessed by the doctor and a consultant and "they said the discharge will carry on." It was agreed by the consultant who gave evidence at the inquest, and by the Trust's legal representative, that thereafter between 1230hrs and Mrs. O'Brien's departure for Pershore at 2025hrs that evening, there is no evidence of any further checks or observations being carried out. In fact, when Mrs. O'Brien was seen on the PDU by family members that same afternoon, it was clear to them that she was in a great deal of pain and distress. They raised their concerns with staff on the PDU, who assured them that she was alright. No member of staff appears to have acted on those concerns, and ensured that Mrs. O'Brien was checked. Those who transported Mrs. O'Brien to Pershore reported to staff there that she "had been in pain on transfer". On her arrival at Pershore at 2100hrs, it was clear to staff there and to an out of hours GP who was called to examine her, that she was in severe pain and very unwell, with a National Early Warning Score ( NEWS ) of 5. An ambulance was called to transfer her back to Worcester, and the paramedics recorded at 0111hrs that her NEWS score had risen to 10. I am therefore concerned at how staff on the PDU at Worcestershire Royal Hospital failed: (a) for some 8 hours to carry out any checks or observations on a patient who was clearly becoming very unwell; and (b) to follow up concerns raised by Mrs. O'Brien's family about her condition on the afternoon/evening of her discharge. I have found, as a matter of fact that, had they not so failed, they were bound to have noticed how unwell she was becoming and her transfer to Pershore would probably not have taken place. This represented a missed opportunity to provide earlier treatment which may have prevented her dying when she did. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] Mrs. O’Brien’s daughter I also have a duty to send a copy of the report to the Chief Coroner. 12. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE David REID HM Senior Coroner for Worcestershire

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0334

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0