A hospital’s decision not to admit a 25-year-old woman suffering from chest pain and breathing difficulties contributed to her death the next day, a coroner has found. 

A hospital’s decision not to admit a young mother who died from pneumonia less than 24 hours later contributed to her death, an inquest has found.

The 25-year-old woman, from Chesterfield, died on 19 May 2023, after she was discharged from Chesterfield Royal Hospital. She had attended the hospital the previous day after becoming increasingly unwell with breathing difficulties, chest pain, a painful and swollen throat and a high temperature.

Her GP had referred her to A&E for urgent assessment.

The inquest heard that she was displaying signs that could indicate sepsis and should have remained in hospital for monitoring and intravenous antibiotics. However, rather than being admitted, she was given the option of returning home with oral antibiotics, which she accepted.

The woman collected her car from her GP surgery and returned home but subsequently became acutely unwell. She was confused and had difficulty recognising her partner and 11-month-old son. She then stopped breathing while sitting on the sofa at home.

Her partner called an ambulance and performed CPR before paramedics arrived, but she could not be saved.

Further observations

Slater Gordon, the law firm which represented the woman’s family, said the hospital’s initial internal investigation concluded the decision to discharge her had been appropriate, and an initial inquest was closed.

Following a legal challenge by the family, however, the Chesterfield Royal Hospital NHS Foundation Trust admitted the decision had been inappropriate, and the woman should have been admitted for further observations. The inquest reopened in February. 

The assistant coroner for Derby and Derbyshire, Anita Davies, said the woman’s vital signs had been significantly outside normal ranges three hours before she was discharged and that she had a very high CRP result, alongside a high heart rate, temperature and respiratory rate. She found that if the woman had been admitted and given appropriate intravenous antibiotics, it was more likely than not that she would have survived. 

“The decision not to admit [the woman] to hospital on the evening of May 18, but rather to offer her a choice between admission or return home, contributed to the death,” Davies said. 

Solicitor Rebecca Dowse represented the family. “They have had to endure not only the devastating loss of a much-loved daughter and mother, but also years of uncertainty while trying to understand how such a tragedy could occur,” she said. 

Following the inquest, medical director of the hospital trust Kevin Sargen said the trust accepted the coroner’s finding, and staff have since undertaken a “thorough review” of the circumstances surrounding the woman’s care. Improvements aimed at strengthening patient assessments, escalation and clinical decision-making have been put in place. 

Sargen again expressed his sincere condolences to the family.