The family of a 31-year-old woman said she was “abandoned” in a hospital corridor for hours before her death, an inquest has heard.
Tamara Davis was said to be in her “most vulnerable moments” when she was left on a trolley in a hallway at Royal Sussex County Hospital for around 10 hours.
She died of multiple organ failure and sepsis caused by influenza on December 13, 2022.
Her sister Miya Davis told an inquest at Horsham Coroner’s Court that Ms Davis, from Brighton, was “made to fend for herself” as she suffered from diarrhoea and was coughing up blood into a small bowl.
Area coroner for West Sussex and Brighton, Joanne Andrews, concluded Ms Davis’ death was from natural causes and that there was no evidence being placed in the hospital corridor contributed to her death.
However the coroner expressed her “substantial concern” over the use of corridors and said she would be writing to Department of Health and NHS England over the ongoing problem in a prevention of future deaths report.
The inquest heard that Ms Davis’ partner Raphael Ifill had rushed her to hospital on December 10, after she had what was thought to be a bad cold for several days, before collapsing at home.
Mr Ifill said they were “left for hours” in the gangway and they kept asking what was happening.
Doctor Andrew Leonard, the consultant who saw Ms Davis, told the court: “Anyone being looked after in a corridor is concerning as it’s a failure of normal care process.”
Dr Leonard told the inquest the practice was becoming “increasingly the norm” across the country in the last few years.
“That is a tragedy,” he said.
He added it was a response to “overwhelming pressure on the system”.
The inquest heard that Ms Davis was in a resuscitation room until 5.30am on December 11, when she was then moved to the corridor where up to 20 patients stayed throughout the day.
She was given one dose of antibiotics, fluids and paracetamol during her treatment, and was moved out of the corridor to another cubicle at 3.20pm.
The inquest heard how her condition deteriorated and she was moved into intensive care later in the night on December 11 before she died on the morning of December 13.
Dr Leonard said he had many “sleepless nights” over what happened to Ms Davis but added: “I still do not think we could have predicted what would happen to her.”
He said he believed Ms Davis had influenza and sepsis caused by the flu strain, which saw 10,000 hospital admissions during the 2022/23 flu season that year where the “majority” of young patients recovered in two to three days.
While Ms Davis was “diagnosable” with sepsis at 4.24pm on December 11, she was not screened for the life-threatening condition until two hours later, the inquest heard.
However Dr Leonard said he was not sure it would have made “any material difference to the outcome” if she was diagnosed earlier.
The inquest also heard from senior sister Alice Edmondson who was on shift that day and asked for Ms Davis to be moved out of the corridor.
The senior nurse described how the corridors are used every day and staff are allocated to work on the corridors where there is limited access to a toilet, it is overcrowded and there is a lack of privacy for the patient.
“We would never move anyone to a corridor out of choice,” she said. “Nobody should be nursed in the corridor.
“I really want the family to know that I, as a senior nurse, I feel upset everyday I go to work that people are in the corridor.”
The inquest heard that having no patients in a corridor was a priority for the trust, which runs the Brighton hospital.
Following the conclusion, Mr Ifill said the hospital “could have done more” and the duty of care was “absolutely shocking”.
“We shouldn’t be changing bed sheets, we shouldn’t be carrying her to the toilet,” he said.
“She felt abandoned. She felt alone,” he said.
“If I fall sick in Brighton I’ve got no faith to go to that hospital. It just feels really bad in there.”
Chief Nurse at The University Hospitals Sussex NHS Foundation Trust, Maggie Davies 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.”