A coroner has ruled that neglect contributed to the death of Theresa Lydon, who waited more than a year to receive a prescribed drug for ulcerative colitis. Mrs Lydon died during surgery at South Tyneside District General Hospital in South Shields on September 18, 2022.
Diagnosis and Drug Delay
Mrs Lydon was diagnosed with ulcerative colitis in May 2021 and prescribed balsalazide, but she did not receive the drug until June 2022—a 13-month delay. Additionally, a referral to Inflammatory Bowel Disease nurses was not progressed, leaving her without community support.
Multiple Hospital Admissions
Between July and September 2022, Mrs Lydon was admitted to hospital four times. Ulcerative colitis and an infection were recognised in July, and treatment began. She was discharged after improvement, but severe colitis persisted. During three admissions in August 2022, the significance of her condition was not fully appreciated by treating doctors; it was only recognised during her fourth and final admission.
The absence of blood tests between August 8 and 15 prevented doctors from identifying the severity of her illness and adopting treatment that could have prolonged her life. The coroner stated this contributed to her death.
Surgery and Death
On her final admission, alternative treatments were ineffective. Mrs Lydon was severely debilitated by lengthy hospital stays, her condition, and treatment. Surgery was deemed the only option but carried very high risk. She died from an intra-abdominal haemorrhage arising from recognised surgical complications. Anti-coagulation, used to prevent pulmonary thromboembolism, contributed to her deterioration but was considered appropriate.
Record Access Issues
The inquest also revealed that doctors at South Tyneside could not access Mrs Lydon's patient records from a hospital admission in Gateshead. Assistant coroner James Thompson said: "Given the two hospitals Mrs Lydon was a patient in are only six miles apart it raises a concern that doctors attending Mrs Lydon in one location are denied access to another hospital records so close at hand... To me, the inability of doctors to promptly access a patient's medical records from other NHS Trusts to provide the best possible care creates a risk of future deaths."
Work to enable "real time" access to patient records is ongoing but not yet complete, according to the coroner.
Coroner's Conclusion and Prevention Report
Mr Thompson gave a narrative conclusion of neglect and issued a Prevention of Future Deaths report on April 21, 2026, which both Gateshead and South Tyneside NHS Trusts have 56 days to respond to. The report also raised concerns about letter formatting to GPs and the requirement for GPs to prescribe drugs diagnosed by specialists in secondary care.
Trust Responses
Dr Shaz Wahid, executive medical director of South Tyneside and Sunderland NHS Foundation Trust, said: "We offer our sincere condolences to Mrs Lydon's family... We fully accept that aspects of her care with us did not meet the high standards we expect. We have taken decisive action to learn from Mrs Lydon’s death." He noted a new pathway for similar symptoms and action on national prescribing guidance.
Carmen Howey, medical director for Gateshead Health NHS Foundation Trust, said: "We offer our sincere condolences to Mrs Lydon’s family... We have carefully considered the coroner's findings and recognise the serious concerns raised about Mrs Lydon's care. We remain committed to working with our partners to make sure patients receive safe, joined up care."
