Matthew Phipps, 56, was admitted to the Romford hospital on July 10 last year and was recognised as being critically unwell, according to a prevention of future deaths report written by coroner Nadia Persaud.

It said the emergency department requested a transfer to the ICU but because it was full this move was delayed. 

Mr Phipps should have been transferred at 10.30pm on July 10 but he was not transferred until 9.30am the following morning, the report said.

At the Walthamstow Coroner’s Court inquest on June 26, 2023, concerns were raised about the lack of contingency plans to ensure intensive care is provided to patients even when the ICU is full. 

An independent consultant anaesthetist said: “I do not understand why one or two of the eight ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU. 

“It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures.” 

Concerns were also raised that Mr Phipps was not observed as closely as he should have been given his condition. 

There were similar delays in carrying out necessary blood tests and commencing renal replacement therapy, the report said. 

Despite these delays, coroner Nadia Persaud wrote: “The inquest has found, however, that Matthew presented to hospital on July 10, 2022 with a likely acute kidney injury, associated with sepsis. 

“His prognosis was very poor, even with optimal treatment. There is no evidence that the failings in the care provided to him contributed to his death.” 

The inquest concluded that Mr Phipps died from natural causes.

But Ms Persaud warned that there is a risk that future deaths could occur unless action is taken by Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT).

A spokesperson for BHRUT said: “We are sorry Matthew Phipps didn’t receive the care he should have expected. 

“We are looking into the reasons behind this and will respond to the coroner in due course.” 


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