Inquest coroner demands hospital response over delay role in death

David Scott died on October 7 last year after deteriorating following a leg amputation.

A coroner ruled that he died as a consequence of naturally occurring disease, contributed to by malnutrition, and in part by a delay in the initial diagnosis and treatment of peripheral vascular disease.

A prevention of future deaths report has now been issued to Warrington Hospital by Charlotte Keighley, assistant coroner for Cheshire.

The inquest heard that on February 2, 2023, Mr Scott attended Warrington Hospital with a history of a non-healing wound to his knee and leg pain.

He was diagnosed with a right knee wound infection and discharged with antibiotics.

On February 9, a physiotherapist identified that he presented with risk factors for peripheral vascular disease, and an urgent referral was made for further investigations on March 8.

By April 4, Mr Scott’s knee wound had increased in size, showing no signs of healing, and he was in pain and struggling with his mobility.

He had not had any communication in respect of the referral and so attended A&E at Warrington Hospital.

On April 7, investigations confirmed chronic limb threatening ischaemia in both legs and surgical treatment options were considered appropriate.

But by April 14, Mr Scott’s wound deteriorated, appearing black and more inflamed, with further blackened wounds appearing on his heel and ankle.

His wounds were not reviewed by the tissue viability nursing team as no referral had been actioned, and when he was seen by the vascular surgeon on April 21, the condition of his leg had deteriorated to the point of ischaemic gangrene.

This had become so severe that he required an above the knee amputation as his leg was beyond repair.

On admission, Mr Scott was considered to be at high risk of malnutrition, and during the admission he lost weight following a reduction in his oral intake.

The inquest was heard at Warrington Coroner's Court

After surgery, he continued to lose weight and experience difficulties with his skin integrity, failing to respond to treatment, with palliative care commencing.

His condition deteriorated further and he sadly died on October 7.

The inquest concluded that Mr Scott died as a consequence of naturally occurring disease, contributed to by malnutrition, and in part by a delay in the initial diagnosis and treatment of peripheral vascular disease.

Coroner Keighley said: “During the course of the investigation, my inquiries revealed matters giving rise to concern.

“In my opinion there is a risk that future deaths could occur unless action is taken,” hence why the prevention of future deaths report has been sent.

Among these concerns are the fact that vascular calcification, a finding that ‘could be normal’ and so conversely ‘could be abnormal’, was not recorded in the original x-ray report.

“This does not appear to be consistent with expected standards and poses a risk that future deaths may occur,” Coroner Keighley said.

“In my opinion, action should be taken to prevent future deaths, and I believe your organisation has the power to take such action.”

The hospital must respond to the coroner by July 21.

The Warrington Guardian approached Warrington and Halton Teaching Hospitals NHS Foundation Trust for a statement.

Executive medical director Dr Paul Fitzsimmons said: “We wish to offer our sincere condolences to Mr Scott’s family for their loss.

“Our focus is always to provide the best possible care for patients.

“We are committed to ensuring we implement any changes that are required to improve patient safety across the organisation.”