Telford hospital boss apologises after opportunity to save 74-year-old woman's life was 'lost'

She had been seen at the Princess Royal Hospital in the town on December 29 and 30, 2022, before her death at the Royal Cornwall Hospital on January 3, 2023.

A coroner was told that there were no concerns over her treatment in Cornwall but her family had their worries over her treatment in Telford.

Medics admitted not picking up the signs that Mrs Roche had a "rare condition with a high rate of mortality". She had presented with incontinence and had looked dehydrated and had been thought to be suffering from a urinary tract infection.

An inquest heard that the hospital was so busy that she was temporarily placed in a paediatric ward but had discharged herself.

Rebecca Race, the clinical director of emergency care at the Shrewsbury and Telford Hospital Trust (SaTH), said changes have been implemented following the woman's death.

"On behalf of the team I am sorry," said Ms Race to members of the family who were asking her a series of in-depth questions online at Thursday's inquest.

"On her second visit to the hospital she was not given due care and I can't apologise enough. Due process would have picked up how ill she was.

"Changes need to be made and we have already done that."

She added that an opportunity was lost when regular blood tests were not carried out.

"An opportunity was lost," said Ms Race. "There was a small possibility that tests could have shown as normal but I think it was more likely that she needed inpatient care."

She added that it was "possible" that Mrs Roche's death could have been prevented by medical intervention.

"An opportunity was lost that could have saved her life," she said.

She added that the trust had made changes to the ways it works.

Senior Shropshire coroner John Ellery was told that Mrs Roche's death was caused by sepsis following a sterocal perforation of her bowel.

The British Medical Association website says it is caused by constipation, which generates pressure against the colon wall, leading to ischaemic necrosis and subsequent perforation.

The family also raised question over Mrs Roche's self-discharge from the hospital on the first visit just before the new year.

But Ms Race said Mrs Roche had been able to make her own decisions.

"The decision to self-discharge is a patient decision," said Ms Race. "She had the capacity to make her own decision. She was spoken to and she declined to stay.

"Efforts were made to get her to stay and to get her to return to the hospital.

"We cannot deprive someone of their liberty or enforce treatment, that would be assault.

"We do not discharge patients because there are no beds. If they need admission, they need admission."

The hospital chief was also quizzed on why she went into a children's ward. Ms Roche said they try not to admit adults onto a children's ward because "it is not a good thing to do."

She added that patients will be found a bed and then moved at a later stage if needed.

"It happens day in and day out," she added.

Recording a conclusion that Mrs Roche died of natural causes coroner Mr Ellery agreed that an opportunity was lost which could have prevented her death.

He said that it was up to the family to take up any other concerns with the trust.

But he asked that the trust to provide details of the actions that they had taken to him and the family following Mrs Roche's death.

SaTh has been asked for more information.