“5 1”

The coroner’s concerns

– 5 1. The inquest heard how the emergency department was, and continues to be, overwhelmed with patients with insufficient staff to care for, monitor and manage those patients. There is continued regular use of agency staff. This directly impacts patients' safety and is a risk of future deaths. 2. The inquest heard how staff failed to consider a diagnosis of sepsis throughout Ms Farndon's admission. There is a concern that staff do not fully understand the variable signs and symptoms of sepsis and there is a risk of future deaths. 3. Ms Farndon’s BP was not recordable when she first presented at the emergency department. It was likely to be very low. This was not considered by the staff concerned and no further attempts were made to assess Ms Farndon’s BP. There is a concern staff do not understand the implication of a low BP, the importance of continued observations when a key parameter cannot be recorded and that this may indicate the patient is seriously unwell. This raises a concern of future deaths.

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, 2024-0186

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