Stuck in her flat for months, she finally left... and never went back

A senior hospital boss apologised to the family of a much-loved grandmother-of-two who died aged 58 at Manchester Royal Infirmary following failings in her care.

A consultant said that but for delays in a CT scan and monitoring of blood thinning medication Lorraine Joseph was on, she wouldn't have died when she did.

Ms Joseph, a mother-of-one from Whalley Range, was admitted to the MRI on May 14 this year after a fall at her flat. She also presented with a swollen right leg and chest discomfort. She passed away on May 20 after suffering a 'sudden collapse' and a subsequent cardiac arrest, Manchester Coroners' Court heard.

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Deputy director of the hospital, Dr Michael Burkitt, acknowledged there were failings in her care as he presented an 'assurance statement' at the inquest in evidence.

He said there were three areas of concern. Dr Burkitt said delays in obtaining a CT pulmonary angiogram - a scan used to diagnose blood clots in the lungs - impacted her 'medication schedules'.

He said the case highlighted 'additional risks associated with prescribing for patients with high or low body mass'. Ms Joseph, who worked as an administrator at the University of Manchester, was said to be morbidly obese and the inquest heard she hadn't left her flat since 2023. She had suffered with sarcoidosis, a rare condition causing the body to develop inflamed lumps, for many years and struggled to get around.

Dr Burkitt said another 'area of concern' highlighted was the 'fragmentation' of her care in being managed in multiple areas of the hospital. He started in his evidence by apologising to the family on behalf of Manchester University NHS Foundation Trust (MFT).

"We know we have got further work to do in the future," he said. Dr Burkitt said changes to 'task allocation' on behalf of ward staff had been made as an 'urgent action'.

In submissions, the family said there were 'multiple instances' of failures that amounted to 'systematic' failures', arguing what happened amounted to gross negligence. But coroner James Lester-Ashworth said he was not minded to return a conclusion referencing any neglect.

The inquest heard that when the delayed scan was carried out, a 'very rare clinical condition' with a poor clinical prognosis was found.

The cause of Withington-born Ms Joseph's death was given as retroperitoneal haemorrhage, a serious condition involving blood pooling in the abdomen. It can be caused, alongside other things, by blood thinners or anticoagulation medication, which she recieved.

A possible pulmonary embolism was 'identified as the primary diagnosis to investigate', when she was admitted said coroner Mr Lester-Ashworth. He said as such, she was given a high dose of anticoagulation therapy in line with her body weight.

Mr Lester-Ashworth said he was satisfied on the balance of probabilities that there were 'delays in the provision of care to Lorraine'.

He said he found there was a 'delay of five days' between the request for the CT pulmonary angiogram on May 15 to exclude the diagnosis of pulmonary embolism. It was carried out on May 20, the inquest heard, when the rare condition was identified but not any blood clots.

The coroner said the 'expected standard of care would have been for the scan to have been undertaken within 24 hours'.

"The significance of the delay was that she was medicated with therapeutic anticoagulation to mitigate risks from presumed embolism for a longer period of time than had the scan been carried out in line with the expected standard of care," said the coroner.

When Ms Joseph was considered for the scan by the radiology team, he said an 'insufficient canular' was found to have been inserted. The coroner said a request was then made for the correct canular so she could have the scan, as well as a CT abdominal scan.

He said: "It is clear from Dr Burkitt's evidence that there was a clear issue with the allocation of the task to restart the canular, which led to further delay."

But Mr Lester-Ashworth said he found it was 'impossible to say' when the retroperitoneal haemorrhage developed and it wasn't possible to identify a cause. The condition, he said, can be 'spontaneous'. "They are very rare and when they do occur, there are high rates of morbidity," he said.

He said he did find it was appropriate to continue anticoagulation until the presumed pulmonary embolism could be excluded.

But he said the monitoring of the blood thinning medication Ms Joseph was receiving should have begun from May 16, but didn't begin until May 20 before she died.

Mr Lester-Ashworth said: "There was a delay and she was not monitored. When Lorraine was monitored, her levels were found to be slightly elevated. However I do find on the basis of evidence that it is also impossible to say on the balance of probabilities that Lorraine's levels were elevated on May 16, when she should have been monitored."

Mr Lester-Ashworth recorded a narrative verdict, which referenced the delays, in line with the evidence heard.

In evidence, Ms Joseph's daughter-in-law, Caitlin Joseph, said she was a proud and private person. In a statement after the inquest, the family said they were 'hugely saddened and disappointed' at the coronial findings.

They said: "Lorraine was admitted to hospital, a place where she and her family thought she would be safe and cared for. The hospital have themselves admitted numerous failures, delays and inactions.

"We are liaising closely with the hospital via the PALS complaints procedures to try and make sure this cannot happen to anyone else. Lorraine is sadly missed, and we are trying our best to make sure she hasn't died in vain."

Ms Joseph said her mother-in-law doted on her two granddaughters. "She was funny, larger than life and loved a rave back in the day," she added. "She was the life and soul of the party."

A spokesperson for Manchester University NHS Foundation Trust said: "We would like to extend our condolences and deepest sympathies to the Joseph family at this extremely difficult time. We strive to provide the best care to our patients, but recognise that the care we provided to Ms Joseph fell short. We accept the findings of the coroner and we will apply the lessons learned from this to our constant work to improve our patients' safety, quality of care, and experience."