NORTH Cumbria Integrated Care have admitted that ‘some opportunities were missed’ after a coroner found that missed tests contributed to a death of a patient in 2023 during a period of strikes by junior doctors.

Daphne Austin was 71 years old and suffered from diabetes. On May 22, 2023, she was admitted to the Cumberland Infirmary in Carlisle after having a stroke.

Whilst in hospital, Ms Austin’s glucose levels were ‘poorly controlled’, and she became dehydrated, an inquest into her death heard.

Ms Austin’s fluid balance was not monitored in an ‘effective manner’ and on June 14 2023 it became apparent that Ms Austin had sustained an acute kidney injury.

Blood testing was not carried out on June 15 or June 16, with the area coroner Robert Cohen saying that this was ‘more likely than not’ because of industrial action by junior doctors.

On June 17, Ms Austin’s condition deteriorated, and it became apparent that she had developed sepsis. Despite treatment, Ms Austin died as a result of that condition on June 18.

In a prevention of future deaths report (PFD) published following the inquest, Mr Cohen said: "I received evidence of the planning that had gone into preparing the trust for strikes.

"However, there was evidence from one of the trust’s consultants that on the day of the strike she had to ‘look after nearly 25 patients’ and that ‘due to the junior doctors' strike on June 14, Mrs Austin did not receive any medical input that day’.

"Another consultant gave evidence that despite being listed as one of the consultants covering the unit, he was probably dealing with other duties on that day.

"In the circumstances I am concerned that the planning that seeks to ensure safe levels of  cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths."

NCIC said that they have plans in place to cover any shortages in staffing and instigated a review into what happened.  

A spokesperson for NCIC said: “We offer our sincere condolences to the family and friends of Mrs Austin. 

“Our initial findings indicate that some opportunities were missed to improve the care delivered to Mrs Austin.

“We have worked with the clinical team to improve the way that fluid intake is monitored and this has been acknowledged by the coroner in their ruling. We are now reviewing the full findings to consider what other lessons can be learned.

“During any period of industrial action we do put plans in place to cover any shortages in staffing.  We are sorry the coroner felt this was a factor on this occasion.”

In response to the prevention of future deaths report, Professor Philip Banfield, chair of the British Medical Association (BMA) Council, said: "We are really sorry this happened. Our heartfelt condolences go out to Daphne Austin’s family; this is a death that could well have been avoided.

“As the coroner notes, NCIC’s lack of preparation and inability to ensure sufficient staffing levels during industrial action significantly contributed to this woman’s death.

“This is exactly why, throughout the strike action, the BMA consistently urged NHS England to prioritise patient safety and ensure proper planning across hospital trusts.

"Throughout all strike periods, the BMA made it clear that during any action taken by members, Trusts must maintain safe and appropriate staffing levels to ensure patient safety.

"Cover across England was provided often by more senior doctors – consultants, associate specialist doctors and specialty doctors as well as specialists.

“We hope the new government will take patient safety as seriously as doctors do and see this avoidable death as a stark warning.

“Our health service needs to be properly staffed and resourced, not just during industrial action but always, as we know there are avoidable deaths and patients coming to harm in hospitals every day, because of consistent understaffing, poor planning and poor management of resources.”