“I am concerned that staff were unable to provide the level of care to Catherine Burns…”

The coroner’s concerns

I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been. I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer. When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met. I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity. However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”. It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity. Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workloads meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.

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, 2018-0132

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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