A woman who died after being left for 10 hours on a hospital trolley in a corridor in A&E was ‘abandoned in her most vulnerable moment,’ an inquest was told.
Tamara Davis, 31, died of sepsis after being left struggling to breathe and coughing up blood in a busy A&E department in December 2022.
She had been rushed to the Royal Sussex County Hospital in Brighton after complaining of breathing difficulties and collapsing at home.
Miss Davis had been diagnosed with a respiratory infection and placed in a resuscitation room and given oxygen.
Tamara Davis, 31 (pictured) died of sepsis after being left struggling to breathe and coughing up blood in a busy A&E department in December 2022
Tamara Davis’ Boyfriend Raphael (right) with her mum Sue (left) and sister Miya outside the Coroner’s court today where they heard Miss Davis died after being left for 10 hours on a hospital trolley in a corridor
Miss Davis was moved into the corridor when another patient needed the room. When Miss Davis’ condition deteriorated further she was moved back to a resuscitation cubicle and transferred to intensive care. She died the following day
But she was moved into the corridor when another patient needed the room and, although her condition became progressively worse, she was left on a trolley in the busy corridor.
At one stage there were 20 patients being treated in the hospital corridor.
When her condition deteriorated further she was eventually moved back to a resuscitation cubicle and from there she was transferred to intensive care.
She died the following day.
Today Joanne Andrews, West Sussex coroner, said she was going to write to the Department of Health and NHS England to voice her concerns over the use of corridors in the treatment of patients.
Recording a conclusion of death by natural causes, she said: ‘In relation to the use of corridors this does to me create a substantial concern.’
However she said: ‘There is no evidence of the patient having been placed in a corridor caused or contributed to her death in these circumstances.’
The inquest heard Miss Davis had been ‘abandoned’ by a healthcare system stretched to the limit.
Tamara Davis’ Boyfriend Raphael outside the Coroner’s court today. The inquest was told Mr Ifill, had desperately phoned emergency services five times to try and get an ambulance
Tamara’s devastated younger sister Miya (pictured together) rushed to the hospital to be by her side
In a statement her sister, Miya, told the inquest: ‘In the few hours [she was in A&E] she was being made to fend for herself. She was abandoned in that corridor at her most vulnerable moments, coughing up blood and suffering from diarrhoea.’
Dr Andrew Leonard, the consultant who treated Tamara in the corridor, said that although Tamara was negative for sepsis on arrival on December 10 her deterioration would have meant she was ‘diagnosable’ at 4.30pm the following day.
However she was not diagnosed until after 6pm because her worsening condition wasn’t flagged to the medical team until then.
He said he would have ‘liked to see a sepsis screening’ earlier rather than when she had deteriorated even further.
Dr Leonard said: ‘Anyone being looked after in a corridor is a concern because it is a failure of normal care processes.’
He said the statements from the family about how they felt Tamara had been failed were ‘heartbreaking’.
He said: ‘Unfortunately we live in a world where more corridor care has become increasingly the norm in the last few years and that is a tragedy and not something any doctor or nurse would say is a good idea but is a result of pressures on the system.’
He said he was ‘unhappy’ Tamara was in a corridor but there ‘was nowhere else to put the patients’.
Of the delay in the sepsis diagnosis, Dr Leonard said: ‘I’m not sure on the balance of probabilities would it have made a difference to the outcome.’
Alice Edmondson, a senior nurse on duty at the time, said: ‘We’d never move anyone to a corridor out of choice. Nobody should be nursed in a corridor.
‘I really want the family to know that I as a senior nurse feel upset every day that people are in the corridor when they shouldn’t be.’
Tamara had been suffering from cold-like symptoms and breathing difficulties and had collapsed at home on the evening of December 10 2022.
The inquest was told her partner, Raphael Ifill, had desperately phoned emergency services five times to try and get an ambulance.
When they failed to come he got a friend to drive Tamara the three miles to Royal Sussex County Hospital.
Tamara, of Brighton, was admitted at 11.14pm and immediately taken through to a resuscitation cubicle in A&E where she was given oxygen.
She was given antibiotics, paracetamol and IV fluids and when her vital signs improved and another patient needed the room at 5.30am she was wheeled out on the trolley into the corridor.
Miya Davis (left) with her mother Sue at the pre inquest hearing into the death of Tamara Davis in March
The inquest heard Tamara spent the next 10 hours on the trolley with other sick patients all around her.
An inquest heard a second dose of antibiotics she was due to receive was missed by medics.
Her condition continued to deteriorate throughout the day and she began to cough up blood and suffered diarrhoea.
The hearing was told her sister, Miya, had to help her to the toilet and because there was no staff available to help she had to change her soiled sheets.
The inquest heard Tamara’s condition continued to worsen and at 3.20pm she was taken into back into a resuscitation room.
Although a medical team was called she wasn’t properly examined for three hours and was later transferred to an intensive care bed where she was put on a mechanical ventilator.
It was later found Tamara had been suffering from the severe H1N1 flu strain.
Tamara Davis (pictured with boyfriend Raphael Ifil). Mr Ifil said: ‘She was failed by a broken system. It was absolutely shocking. There was an absolute failure in the duty of care’
The inquest was told that Tamara failed to respond to treatment and her condition continued to deteriorate in intensive care and she died at around 11.15am on December 13.
Her cause of death was given as sepsis and multiple organ failure brought on by broncho-pneumonia and influenza.
After the inquest Miya said: ‘It was like a warzone. It was terrible in there. A hospital is somewhere where you are meant to feel safe if you’re sick but that hospital was anything but.’
Her partner Raphael Ifill said: ‘She was failed by a broken system. It was absolutely shocking. There was an absolute failure in the duty of care.’
He added: ‘She was an amazing person, very strong and very loyal. She would try and help anyone at all. She was my world.’
Maggie Davies, chief nurse, said: ‘We wish to extend our heartfelt condolences to Miss Davis’ family and friends.
‘We entirely accept that the experience Tamara, and her family, had in the ED corridor before admission to intensive care fell short of the standards our patients and families should expect – that is a matter of deep regret, and we are truly sorry.
‘We also acknowledge the coroner’s concerns about the provision of corridor care, and we are committed to working with partners to continue to try to resolve this issue for patients and families.’