Hospital made changes after nurse death - coroner

Changes have been made at an NHS trust where a student nurse died from sepsis, a coroner has said.

Zoe Bell, 28, died in December 2022 after waiting 12 hours in A&E at Stoke Mandeville Hospital in Aylesbury, Buckinghamshire, where she had been working shifts.

An inquest last year concluded Ms Bell died of natural causes and the hospital was not to blame - but said the hospital did have some "learning" to do.

Crispin Butler, senior coroner for Buckinghamshire, has written to Buckinghamshire Healthcare NHS Trust, outlining how some of the shortcomings and issues identified following Ms Bell's death had been addressed. The trust said it had taken learning points on board.

In his letter, Mr Butler listed nine main areas of concerns identified following Ms Bell's death, and what changes have been made to address them.

Mr Butler said that it was "clear from evidence given" during the inquest that "there has been change within the Trust."

The inquest heard how Ms Bell arrived at the hospital at 22:14 GMT on 23 December 2022 but was not assessed by doctors until 07:30 on Christmas Eve.

It found hospital staff had not kept a log of Ms Bell's condition between 23:34 on 23 December and 10:00 the next day.

In his letter, Mr Butler said Ms Bell's case had shown shortcomings in carrying out or recording of regular observations for a significant period of time.

There is now a health care assistant allocated to the waiting room area to take regular observations, he added.

Regular staffing levels have also increased from 18 to 22 per shift, the letter said.

A mandatory sepsis screening tool has also been brought in.

"The unusual and tragic circumstances of Zoe's death serve to highlight the importance of individual care elements for patients whose needs are not as complex," Mr Butler wrote.

The coroner said he had not raised a report to prevent future deaths but instead reflected on things that have been identified and addressed through Ms Bell's death.

Andrew McLaren, chief medical officer of the trust, said it had "identified a number of learning points" which it was addressing.

"It is noted that the coroner concluded that, sadly, there was not an opportunity to provide any care following Zoe's admission to hospital which would have avoided her decline, and she died of natural causes from a rare combination of infections," he said.

"Improvements to our emergency care pathways have included increasing staffing,  extending the hours of the urgent treatment centre and last month we opened an additional medical ward," he added.

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