Coroner’s concerns over woman’s death in Rotherham Hospital after being admitted with a broken hip

Louise Slater, coroner for South Yorkshire East, contacted Rotherham NHS Foundation Trust over the death of Anne Hawkes.

Ms Slater concluded that an infection occurred due to surgical wound breakdown because of pressure caused by fluid overload as a result of “poorly managed” cardiac failure.

The coroner ruled that a “lack of communication” between services within the trust led to a “delayed and incohesive approach to the wound management”.

Mrs Hawkes was admitted to the hospital on May 3, 2023, following a fall at home. She recovered well after surgery and was fit for discharge by May 11, but remained on the orthopaedic ward while awaiting social care input.

Ms Slater’s report found that Mrs Hawkes’ cardiac failure was not properly monitored – and she had gained 34kg by May 22.

The increase in weight was only addressed from May 17 – but by this time the patient was “very unwell” with fluid retention and other issues.

Mrs Hawkes was seen by specialist cardiac failure nurses on May 22 and given IV medication.

She was transferred to the cardiology ward on May 25, and despite the wound starting to break down on June 3, a referral to tissue viability was not made until the 29th.

By this time, tissue viability staff were unable to assist and a surgical washout was declined by Mrs Hawkes, so the wound was managed with dressings and antibiotics. She deteriorated and died on July 15, as a consequence of multi-organ dysfunction.

The coroner found that the delayed referral to cardiology led to “sub­ optimal management of her cardiac failure, which in turn is implicated in her death”.

Dr Jo Beahan, medical director at the trust, said: “Our thoughts and condolences are with Anne’s family and friends. We take these matters very seriously. We have taken on board the findings of the report and will be taking steps to address the concerns identified.

“We do have processes in place within the trust for clinicians to refer patients for urgent cardiology advice. We will be reviewing why this did not happen for Mrs Hawkes and ensuring we take appropriate actions to prevent this happening in future.”