Woman died from sepsis 'due to string of blunders at hospital where 25 patients were being treated in corridors after junior doctor strikes' inquest hears

A woman died from sepsis due to a string of failings at a hospital where more than 25 patients were crammed into corridors due to "added pressures caused by striking doctors."

Norma Campbell, 59, attended the emergency department at Whipps Cross Hospital on January 13 2024 at around 12pm.

Her sepsis was recognised very early, but the hospital medics who were working failed to follow necessary steps set out in NICE guidelines.

Nadia Persaud, Coroner for East London, who carried out the inquest into her death, is now calling for action to prevent a repeat, amid claims strike action made the situation worse.

In a prevention of future deaths notice to Barts Health NHS Foundation Trust, which runs the hospital, she wrote: "The emergency department was exceptionally busy due to patient acuity and patient numbers.

"Pressures were added to by the absence of a number of locum doctors, due to a pay dispute with the trust.

"Sepsis was recognised very early in her presentation, but the prompt and necessary sepsis care set out in the NICE guidelines was not provided.

"In particular, Mrs Campbell required care in the resuscitation area of the emergency department, but there were no resuscitation beds available."

There was a delay of around 30 minutes in administering intravenous antibiotics and a two-hour delay in administering clarithromycin following a prescription.

Ms Persaud added: "There was a failure to robustly fluid resuscitate Mrs Campbell whilst closely monitoring the clinical effect of this. There was no fluid balance analysis, abnormal findings such as the lactate level of seven were not appropriately monitored and responded to."

At 9.52pm the same day, whilst still in the majors area of A&E, Mrs Campbell suffered a cardiac arrest.

Efforts were made to resuscitate her, but she died in the early hours of January 14.

Persaud said: "Mrs Campbell was a 59-year-old lady who had no underlying chronic disease. On the balance of probabilities, had she received a NICE guideline compliant and National Early Warning System compliant level of care, her death would have been avoided."

Doctors had been striking on and off at the hospital, as part of the junior doctors strikes, since the start of January, with one of the longest six-day strikes having taken place ahead of her admission.

Ms Persaud wrote: "The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity. The inquest heard that overcrowding in A&E is a national concern.

"The inquest heard that it is not uncommon to find patients in corridors when they need to be monitored. On 13 January 2024 there were more than 25 patients in the corridors. They were not receiving an appropriate level of care."

"There are often insufficient numbers of resuscitation beds. Patients who require a resuscitation area level of care are often directed to the majors area of A&E.

"The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients.

"In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care.

"There is no electronic observation system in place within the A&E department of Whipps Cross Hospital.

"Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.

"The Critical Care Outreach Team (CCOT) do not currently attend A&E for deteriorating patients. The overcrowding and lack of resourcing in A&E highlights the need for the CCOT to provide support to A&E patients as well as patients on the ward.

"In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

In December 2024 a report by the Care Quality Commission (CQC) said the trust "required improvement" in its emergency services after its inspectors found up to 30 people waiting to be admitted to A&E, with many being treated in corridors, and some people waiting up to 12 hours to be seen by a clinician after being triaged.

This week it emerged that the number of claims against Barts NHS Trust for A&E negligence had risen year on year since 2019, resulting in over £15m in settlements, figures from Medical Negligence Assist revealed.

Barts Trust operates Whipps Cross Hospital in Leyton, in addition to The Royal London, St Bartholomew’s and Newham Hospitals. They provide healthcare to around 2.5 million people in East London.

The causes of the rise in A&E negligence claims in Barts NHS Trust, and the UK as a whole, are likely as a result of overwhelmed NHS services, caused by staff shortages, long waiting lists and overcrowding. The pressure on waiting lists has also increased the strain on A&E services, with some patients having to wait days at a time for treatment, often spending time on hospital corridors.

The trust, which has 56 days to respond, said: "We offer our heartfelt condolences to Mrs Campbell's family and loved ones during this very difficult time. We are carefully reviewing the coroner's report and will provide a full response by August 2025, setting out the steps we are taking to learn from this and improve patient care."