A West Midlands family have been commended by Coroner for “tenacity and perseverance in seeking answers”.

A West Midlands family have been commended by Coroner for “tenacity and perseverance in seeking answers”.

Russell’s Hall Hospital falls under the Dudley Group NHS Foundation Trust.

What was the case?

In July 2017 Mrs Dunn was admitted to Russell’s Hall Hospital after developing swelling of her tongue which was causing her difficulty in breathing. Whilst in hospital, it was clear Mrs Dunn required an emergency tracheostomy in order to help secure her airway, however, a tracheostomy kit was unavailable.

Following this there was then a delay in finding a basic scalpel to perform the emergency procedure which would have helped Mrs Dunn to breathe. Mrs Dunn went on to suffer a lack of blood flow to the brain and a cardiac arrest, and sadly died 5 days later. Medical experts giving evidence have confirmed that the unnecessary delays in Mrs Dunn’s care had contributed to her death.

Initially, the hospital reported Mrs Dunn’s death to the Coroner, however failed to mention the concerns which had been raised around her treatment and the delays in securing the lifesaving equipment. As a result, an Inquest was not listed at the time. The family of Mrs Dunn were also not informed of the sequence of events until they requested copies of her medical records almost two years later.

After the family were made aware of the real sequence of events, we were instructed to contact the Coroner and provide further information so that the death could be reconsidered. After detailed submissions to the Coroner, an Inquest was opened and took place on 3 – 5 March 2021.

What was the outcome?

Following a review of Mrs Dunn’s case, it was clear that the lack of provisions set in place by Russell’s Hall Hospital had contributed to her death. The hospital staff were unable to locate the necessary equipment, including a basic scalpel, and the Coroner found that this resulted in delays in providing the treatment which Mrs Dunn urgently required.

During the inquest Black Country Coroner Zafar Siddique commended Mrs Dunn’s family for their “tenacity and perseverance in seeking the proper answers to the questions they have had for so long.”

Chartered Legal Executive Michael Portman-Hann said the family were grateful to the Coroner for recognising their concerns and investigating the sequence of events which led to Mrs Dunn’s death on 17 July 2017. “There was no formal investigation at the time of Mrs Dunn death and her family were not told about the circumstances until they requested Mrs Dunn’s medical records over 18 months later.” “Her family had so many questions and concerns about the care she received and this inquest has helped provide them with the answers they so desperately wanted and deserved.”

Mrs Dunn’s Granddaughter, Sarah George, added: “Something about the care provided never really felt right to us, which is why we requested the medical records and looked into it further. We are so glad that we did, and didn’t just ignore our gut instinct, as had we not pushed for answers we would never have known about the issues which occurred in the treatment provided. We hope that some good can come out of this and that the Trust recognise it is important that open investigations are performed and families made aware of potential issues in treatment so that further distress can be avoided.”

Chief Executive for the Dudley Group NHS Trust, Dianne Wake, said “We would like to offer our sincere condolences to Dorothy Dunn’s family on her very sad death in 2017 while she was in our care. We fully accept the conclusion and findings of the Coroner”. In addition, the Chief Executive of the Trust was asked to write to the Coroner and confirm that all future reports will include details of any concerns raised by treating clinicians, so that a full consideration of the facts can occur before deciding to list an Inquest or not.

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