Jacqueline O'Brien
24 Jun 2026 · Coroner David Reid · Worcestershire
The coroner's concerns
1. lack of monitoring of deteriorating patient
“During the course of the inquest I heard evidence giving rise to concern.”
2. abnormally high liver function tests
“On 29.10.25 Mrs [name redacted]'s Liver Function Test ( LFT ) results had been abnormally high ( Gamma GT: 545, ALT: 200 ). The plan was to repeat those tests a few days later.”
3. gastrointestinal pain and loose stools at transfer
“At around 2300hrs on the night of 2.11.25 Mrs [name redacted] was transferred to the Pathway to Discharge Unit ( PDU ) at Worcestershire Royal Hospital with a view to her discharge for further rehabilitation to Pershore Community Hospital. At the time of her transfer to the PDU, it was recorded in her notes that she had been experiencing gastrointestinal pain for the previous hour, and had passed loose stools.”
4. abnormally high liver function tests preventing discharge
“At 1200hrs on 3.11.25 a trauma and orthopaedic doctor recorded that Mrs [name redacted]'s discharge could not go ahead because of these still abnormal LFT results. The note continues: "Escalated the problem to the capacity team, and they instructed that the discharge will proceed."”
5. family concerns about patient condition ignored
“In fact, when Mrs [name redacted] was seen on the PDU by family members that same afternoon, it was clear to them that she was in a great deal of pain and distress. They raised their concerns with staff on the PDU, who assured them that she was alright. No member of staff appears to have acted on those concerns, and ensured that Mrs [name redacted] was checked.”
6. severe pain and unwell condition on transfer to Pershore
“Those who transported Mrs [name redacted] to Pershore reported to staff there that she "had been in pain on transfer". On her arrival at Pershore at 2100hrs, it was clear to staff there and to an out of hours GP who was called to examine her, that she was in severe pain and very unwell, with a National Early Warning Score ( NEWS ) of 5.”
7. rising NEWS score indicating critical deterioration
“An ambulance was called to transfer her back to Worcester, and the paramedics recorded at 0111hrs that her NEWS score had risen to 10.”