A student nurse who died of sepsis on Christmas Eve was left waiting in A&E for 12 hours because of a shortage of beds, an inquest has heard.
In a hearing at Buckinghamshire coroner's court, 'insufficient bed stock' was identified among factors that contributed to the death of Zoe Bell, a 28-year-old who had been working a series of long shifts at Stoke Mandeville hospital in Aylesbury.
Andrew McLaren, chief medical officer at Buckinghamshire Healthcare NHS Trust, also said there was a lack of observation on Bell, who arrived at the hospital at 10.14pm on 23 December 2022 but did not receive an initial doctor's assessment until 7.30am the following morning.
'There were a number of interactions with Zoe which we accept were not fully documented,' McLaren told the hearing.
'It wasn't that nobody was coming to see her, but they were making clinical decisions at the time that she was OK.'
McLaren said the hospital's A&E department was under intense pressure, with the number of patients frequently exceeding the number of beds.
'It was recognised that we were a hospital with insufficient bed stock,' said McLaren.
Bed numbers at Stoke Mandeville have since improved following the opening of a new hospital ward, the inquest heard.
Zoe Bell, 28, had been taking on extra shifts at hospitals in Buckinghamshire to help finance the last stage of her studies, a coroner was told.
Ms Bell died on Christmas Eve, 2022, after waiting 12 hours in A&E. At an earlier session in the hearing, the coroner was told the delay in treatment contributed to her death.
Stoke Mandeville hospital no longer uses agency staff and has increased staffing numbers in A&E, according to the chief medical officer at Buckinghamshire Healthcare NHS Trust.
Bell, of High Wycombe, had been taking on extra work at hospitals in Buckinghamshire to help finance the final stage of her studies.
She fell ill with a sore throat after finishing her last 12-hour shift on Sunday 18 December, and was rushed to the hospital five days later.
McLaren said an 'incredibly rapid deterioration' in Bell's condition after 8.30am on December 24 took doctors by surprise. She was taken into surgery at 3pm and was pronounced dead at 6.45pm after suffering from influenza and blood poisoning, according to family solicitors Leigh Day.
Asked by counsel representing Bell's family what steps the trust had taken since her death, McLaren said the hospital no longer used agency staff and had increased staffing numbers in the A&E department.
He also said that there were more senior medical doctors on the wards.
McLaren added that the working environment had 'changed considerably', with the department team ing privately every two hours and encouraging reviews of sepsis documentation.
Sepsis screening in the department was at 92% in September 2024.
'We are an organisation that does try to learn from each and every event,' said McLaren
Bell's father, stepmother and stepbrother were all in attendance at the inquest alongside several of her friends.
Addressing the family during the inquest, senior coroner Crispin Butler said: 'I wish you well for what will be a very difficult week next week.'
The inquest is expected to conclude later on Thursday.