Inquest for Winchester preservation campaigner who died of sepsis

Orthopaedic consultant, Kevin Conn, admitted at an inquest that staff failed to "adhere to best practice” when Shione Carden, 86, was admitted to hospital in 2021.

Mrs Carden, of Christchurch Road, chaired the City of Winchester Trust’s planning appraisal group for 20 years and was praised by her friends and family for her sense of humour and enjoyment for life.

She died at Basingstoke and North Hampshire Hospital in the early hours of February 4, 2021 following surgery on an infected hip replacement.

READ MORE: Tribute paid to senior figure in City of Winchester Trust

In a statement read out by senior coroner Christopher Wilkinson, Shione’s husband Michael Carden said: “There were a series of spells which caused her health to deteriorate but her sense of humour and character returned.

“I have no complaints over any of her treatment and she always praised the NHS. However, I have one point of advice – if symptoms of sepsis were more widely known, I and others may have reacted sooner.”

Mr Carden called his wife’s GP, Dr Becky Mitchinson from St Clements on February 2, after two days of increasing confusion and low blood pressure.

Shione Carden

The former City of Winchester Trust trustee was admitted to Royal Hampshire County Hospital before being transferred to Basingstoke during the night, ready for a procedure to remove the fluid around her hip.

It wasn’t until Mrs Carden suddenly deteriorated that medical staff realised she had septic shock and gave her antibiotics.

Although, the inquest at Winchester Coroners’ Court on Monday, August 14 concluded that Mrs Carden ultimately died of natural causes, Mr Wilkinson highlighted missed opportunities that he hopes the trust can improve on including identifying sepsis symptoms earlier, spreading awareness and creating a culture where more junior doctors feel they can speak up.

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Speaking at the inquest, consultant Mr Conn, said: “She would have been seen as a lady with hip pain who was confused.

“With hindsight, it’s likely that she was showing signs of sepsis. One crucial point was the confusion, when she was usually alert.

“Failure to recognise the confusion as a new factor lulled people into a false sense of security. The ambulance record of the increase in confusion should have triggered a critical appraisal.

“The continuity of care is very important. The risk of transfer also meant that physicians couldn’t monitor subtle changes.

“I don’t think earlier antibiotics would have changed the ultimate outcome. I hope we’ve learned from it and I really apologise to the family that we did not adhere to best practice.”

Mr Wilkinson said: “It appears more than likely that the infection may have lain dormant for quite some time.

“There was a failure to follow trust protocols but this has not contributed to her death. It was a naturally occurring disease process that would have only been at best slowed down.

“Perhaps there is a gap in providing good and clear information to families that every significant surgery carries a risk of sepsis. People should be better informed on the symptoms so they can contact their GP in a timely manner.”