Man died after GP's calls to hospital were missed

A coroner said there was a "risk future deaths could occur" unless action was taken after a man with sepsis died after a GP's calls to a hospital went unanswered.

Terrence Frost died of natural causes on 17 July 2024 at Ipswich Hospital, in Suffolk, after he collapsed and suffered a cardiac arrest.

The 84-year-old had gone in with a serious infection or inflammation following advice from his GP, who tried to contact the hospital ahead of his arrival to no avail.

Nigel Parsley, senior coroner for Suffolk, said the doctor's "inability to promptly communicate" with its medical assessment unit or A&E department was a concern.

In a Prevention of Future Deaths report, he said: "[That] could lead to future deaths where suspected sepsis or other life-threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence's had at the time of his arrival.

"I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the medical assessment unit extremely difficult, with internal hospital telephone calls frequently going unanswered."

Frost had been admitted to Ipswich Hospital on two occasions in the days before his death.

On 11 July 2024, he went in for surgery to improve blood flow to his left leg and foot, before being discharged the next day.

He returned on 14 July with abdominal pain and rectal bleeding before being discharged again the following day with no diagnosis.

On 16 July, he was visited by his GP surgery's paramedic at his home over concerns about his condition.

The results of "urgent" blood tests were "concerning" and indicated a possible serious infection or inflammation, so his GP told him to go to hospital.

She called its medical assessment unit to alert them to his arrival, but, after 30 minutes of trying, she failed to get an answer.

She then spent a further period of time telephoning the A&E department but again could not get through, despite Frost being "significantly unwell".

Frost then spent five hours in the hospital's A&E unit before eventually being readmitted as a failed discharge.

Observations taken at the time suggested he had not yet developed sepsis, and, despite undergoing tests, no diagnosis was given.

He was said to have "appeared reasonably stable" until he collapsed and had cardiac arrest at 21:22 BST before dying at approximately 22:20.

A postmortem examination identified that Frost suffered from significant cardiac disease and significant vascular disease.

A pathologist also identified that sepsis was a factor in his death, "although evidence of any infection could not be found".

Parsley sent his concerns to the East Suffolk and North Essex NHS Foundation Trust, which runs Ipswich Hospital.

"In my opinion action should be taken to prevent future deaths, and I believe you have the power to take any such action you identify," he said in his report.

Catherine Morgan, chief nurse, said the trust would "provide the coroner with our full response in due course".

"We would like to extend our deepest sympathies to Mr Frost's loved ones for their loss," she said.

"Providing safe, compassionate care is our highest priority, and we take the concerns raised in the Prevention of Future Deaths report extremely seriously."

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