Phyllis Hart

I am Emma Serrano, Acting Senior Coroner of Staffordshire.

On the 17 th April 2023 2023, I commenced an investigation into the death of Mrs Hart.  The investigation concluded at the end of the inquest on 16 October 2024.  The conclusion of the inquest was a conclusion of natural causes. The cause of death was: 1a) Sepsis, 1b) Acute Limb Ischaemia 1c) Peripheral vascular disease II) Diabetes mellitus

i) Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023.  On the 21 Marc 2023 she started to show signs of having a ischaemic leg.  On the 27 th march vascular specialist review was requested.  There is no vascular team located on the County Hospital, so the review was delayed for 4 days until the Vascular Consultant was next at the County Hospital. ii) At the review, the decision was made that Mrs Hart was for palliative care only.  She passed away on the 8 April 2023

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.  – There is no vascular team in hand at the County Hospital in Stafford, were urgent Vascular opinion required.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.