A South London hospital has been heavily criticised by a coroner for providing disjointed care that contributed to the death of a 74-year-old woman from sepsis.
Preventable Tragedy
Joan Talbot died of sepsis at King's College Hospital in Lambeth on August 14, 2022, following complications from a urinary tract infection and proctocolitis. The tragic case has prompted a formal Prevention of Future Deaths report highlighting significant failures in her medical care.
A post-mortem examination revealed that Mrs Talbot's bladder had been destroyed by recurrent infections stemming from radiotherapy treatment she received for cervical cancer back in 1987. This long-term damage created ongoing health challenges that required careful management.
History of Hospital Admissions
In the months leading to her death, Mrs Talbot was admitted to hospital three times during March 2022 with urinary tract infections directly related to scarring from her earlier radiotherapy. Her condition necessitated stenting - the insertion of a hollow mesh tube to keep blocked passageways open.
This medical intervention unfortunately led to recurrent bouts of diarrhoea, which was sometimes bloody. Despite these repeated admissions and symptoms, the significance of her deteriorating condition wasn't fully recognised by medical staff.
When Mrs Talbot was admitted for the fourth and final time on August 14, 2022, she presented with worsening bloody diarrhoea and received a working diagnosis of acute colitis. While awaiting a CT scan to investigate her symptoms, she developed sepsis and was found to have a dislodged ureteric stent.
Systemic Failures Identified
Assistant Coroner Liliane Field identified critical gaps in Mrs Talbot's care, noting that each hospital admission placed her under a different medical team, resulting in poor continuity of care. The coroner emphasised that the pattern of her symptoms across multiple admissions wasn't properly recognised or investigated in a timely manner.
In her Prevention of Future Deaths report published on November 11, 2025, Ms Field wrote: "Mrs Talbot had been admitted on three occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team."
The coroner acknowledged that the trust has since introduced a new record system with potential to improve care continuity, but criticised the organisation for not properly evaluating how this system could prevent similar scenarios or whether further refinements might be necessary.
The post-mortem ultimately determined that Mrs Talbot's acute colitis resulted from ischaemic colitis caused by radiation injury. Despite emergency treatment including kidney drainage and sepsis management, her condition continued to deteriorate.
Trust Response and Requirements
King's College Hospital NHS Foundation Trust has been ordered to take action to prevent future deaths and must provide a detailed response to the coroner's report by January 6, 2026.
In an official statement, the trust said: "We wish to extend our deepest sympathies once again to the family of Mrs Talbot. We accept the Coroner's report and will work through it in detail to ensure the robustness of actions to prevent similar situations from occurring in the future."
The coroner's investigation into Mrs Talbot's death began on September 6, 2022, and concluded nearly three years later with the inquest on June 26, 2025. The case highlights ongoing challenges in maintaining continuity of care within large NHS trusts and the devastating consequences when communication between medical teams breaks down.
