A coroner has issued an urgent warning after a 'frail' pensioner contracted sepsis during a 200-mile hospital transfer overseen by staff who 'weren't medically trained'. Critically-ill Monica Wood died the day after she was moved to Stepping Hill in Stockport, an inquest heard.
Patient developed chest infection before transfer
The 66-year-old, who had dementia, had been admitted to the Royal London Hospital a fortnight earlier after suffering a bleed on the brain in a fall. But while waiting to be transferred to a hospital closer to her home Mrs Wood developed a chest infection which was 'not recognised' by medics.
Coroner Adrian Farrow said that infection then developed into sepsis 'coincident' with the journey north. But, Mr Farrow said, the hospital did not have 'any medically trained crew to undertake monitoring of her condition during the journey'.
By the time she arrived at Stepping Hill Mrs Wood had 'developed multi-organ failure which her underlying medical conditions and the effects of the recent brain injury left her unable to overcome'.
Inquest findings and cause of death
An inquest at Stockport coroner's court heard Mrs Wood's cause of death was acute heart failure, multi-organ failure of the liver, kidneys and lung, sepsis from hospital acquired pneumonia and vascular dementia, peripheral vascular disease, hypertension, ischaemic heart disease and traumatic brain injury.
The two-day hearing in July this year concluded Mrs Wood 'died from the consequences of overwhelming infection contracted in hospital whilst recovering from a brain injury sustained in an accidental fall'.
Coroner raises urgent concerns
Now Mr Farrow has raised urgent concerns about Mrs Wood's death. In a prevention of future deaths report sent to the chief executive of the trust which runs Royal London Hospital he wrote: "There was no review of her condition and her fitness for transfer to a distant hospital on the day of her transfer on November 19, 2025, when the inquest found that she had begun to develop pneumonia.
"The suitability of the non-emergency patient transport was not reviewed in the light of the changes to her condition with the result that there was no nursing or clinical observation or monitoring of her condition for a period of over seven hours at a time when she had raised NEWS 2 scores [a system used by medics to assess how sick a patient is] and a chest infection."
He added: "She was medically frail with several co-morbidities including dementia and vascular disease and on arrival at Stepping Hill Hospital in Stockport, she had developed sepsis which led to multi-organ failure, which brought about her death."
Trust responds and revises policies
Warning there is a 'risk that future deaths could occur unless action is taken', Mr Farrow said there appears to have been 'no mechanism' to review a patient's suitability for travel or the 'suitability of the chosen transport and crew for a patient whose condition has materially changed from the point of booking to the point of transfer'.
In response Barts Health Trust, which runs the Royal London, said it was 'very sorry' for Mrs Wood's death. The trust said it accepted the coroner's findings and had since reviewed its discharge and patient transfer policies.
It added: "The revised requirements will mandate a documented clinical reassessment before departure where a transfer has been delayed, where there has been any material change in clinical condition, or where the planned journey presents additional risk because of its duration or distance."
