North Cumbria Integrated Care NHS Trust

I am Robert Cohen HM Assistant Coroner for Cumbria

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made

On 22 June 2023 I commenced an investigation into the death of Daphne Gillian AUSTIN.
The investigation concluded at the end of the inquest on 8th August 2024. The conclusion
of the inquest was a narrative.

I found that the medical cause of death was:

1a Urosepsis and Acute Kidney Injury
1b
1c

 II   Right cerebral Infarct 

Ms Austin was 71 years old. She suffered from diabetes. On 22nd May 2023 Ms Austin was admitted to the Cumberland Infirmary, Carlisle. She had had a stroke. 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. On 14th June 2023 it became apparent that Ms Austin had sustained an acute kidney injury. Blood testing was not carried out on 15th or 16th June, it is more likely than not that this was because of industrial action by junior doctors. On 17th June 2023, Ms Austin’s condition deteriorated and it became apparent that she had developed sepsis. Despite treatment, Ms Austin died as a result of that condition on 18th June 2023.

Neglect (being the ineffective monitoring of Ms Austin’s fluid balance and the fact that blood testing was not carried out on 15th or 16th June 2023) contributed to Ms Austin’s death. 

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. –

(1) I received evidence of the planning that had gone into preparing the trust for strikes.  However, 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.   

In my opinion action should be taken to prevent future deaths and I believe you North Cumbria Integrated Care NHS Trust have the power to take such action. 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th October 2024. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the family of Ms Austin. I  have also sent it to the Secretary of State for Health and the British Medical Association who may find it useful or of interest given the potential national aspects of these  concerns.   

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary  form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your  response, about the release or the publication of your response by the Chief Coroner.