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Second Inquest into death of Elsie Brooks concludes with critical findings’

Updated: Apr 27, 2022

Today the second inquest investigating the death of beloved 89 year-old mother, Elsie Brooks, concluded at Southwark Coroner’s Court. This inquest was hard won by Elsie’s daughters, Janet and Margaret Brooks, who succeeded in obtaining a fresh inquest by an Order of the High Court in 2018.

Elsie died at King George Hospital on 6 January 2010 from a septic infection, weeks after an elective hernia repair surgery.

Experts to the second inquest stressed that as the surgery was not mandatory, everything about Elsie’s pre-operative condition and post-operative care had to be in line to justify going ahead with the procedure. However Elsie was not placed in a surgical ward but on a contingency ward, which the Coroner concluded was unfit for any patient let alone one who had undergone major surgery.

Pre-operatively, the Coroner found that “there was a lack of communication between nursing, junior doctors and the Consultant undertaking surgery. … Had [the Consultant surgeon] been aware of [her possible urinary infection] it is clear that he would not have proceeded with the surgery, on balance.”

Significantly, the Coroner accepted that Elsie’s consent was not respected in the decision to operate despite knowledge that there was no High Dependency Unit (HDU) bed available.

Post-operatively, the Coroner found that “the care received in the contingency ward was inadequate and more than minimally contributed to the chest infection that subsequently led to her death.”

After over a decade of disciplinary, court, and inquest hearings, the family have finally received recognition of the Trust’s lack of urgency toward their mother’s decline in December 2009 and January 2010.

Janet and Margaret Brooks, daughters of Mrs Elsie Brooks stated:

The Inquest showed that there was a significant delay in providing our mother with potentially life-saving antibiotics to treat her sepsis in January 2010. This has always been a major concern for us and the evidence we heard confirms that these ought to have been given much earlier.

Importantly to us, the Inquest showed that our mother aspirated her own vomit as a result of the lack of nursing care and equipment on the contingency ward, and that this contributed to her fatal chest infection.

We are relieved that the Coroner recognised that our mother, as well as us, would not have consented to the surgery without an HDU bed.

We have fought 11 years to find out why and how the Trust failed our mother. After over a decade of pouring over incomplete records, witnessing failures by the first inquest to identify and question key witnesses and of the BHRUH Trust to properly disclose medical records, we finally have a Coroner’s conclusion.

We hope that the Trust will continue to learn lessons from these failures and that we have spared other families from the neglect our mother suffered.

Daniel Cooper, solicitor for the family stated:

This result is long-awaited by the family. No family should have to endure the pain of watching their loved one deteriorate in a hospital ward that is simply not fit for purpose. We are pleased to learn that the Trust have brought in a number of changes since 2009 and hope that this case continues to serve as a reminder on the importance of the placement, planning and communication for vulnerable surgical patients.

Janet and Margaret Brooks, daughters of Mrs Elsie Brooks, were represented by Daniel Cooper and Emma Gilbert of Imran Khan and Partners and Martin Haukeland at 42 Bedford Row Chambers.

Please contact or 0207 404 3004 for further details.


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