Retired nurse Pat Dawson would have been ‘horrified’ by how the NHS ‘failed’ her, her son said (Picture: Lancs Live/MEN Media)
Staff at an ‘over-stretched’ hospital let a ‘fit and healthy’ former nurse die after reading ‘do not resuscitate’ on the wrong patient’s notes.
Pat Dawson, 73, was enjoying retirement after devoting three decades of her life to the NHS.
But when she was rushed to A&E for the first time ever – with suspected bowel obstruction – it fatally failed her, an inquest found on Tuesday.
The emergency department at Royal Blackburn Hospital, Lancashire had been declared ‘over capacity and over-stretched’ an hour before Pat visited with her son John on September 19 last year.
She was dead within four hours, something that ‘stunned’ even the paramedic who brought her in, according to John.
If staff had just checked the right person’s notes, she likely would have survived, a coroner ruled.
In a statement read to the inquest, John said: ‘It is beyond belief the catastrophic way in which she was failed, not only by one individual but by doctors who have sworn the Hippocratic oath to do no harm and our mum paid the ultimate price.’
More than 90 patients were waiting to be seen in A&E that night.
All eight resus bays – where the most seriously ill or injured patients are seen to – were full.
Each nurse had an unlimited number of patients to care for.
Emergency consultant Dr Ahmad Alabood said staff ‘were rushing’ in the ‘significantly over-stretched and over-crowded’ A&E department (Picture: Anthony Devlin/Bloomberg via Getty Images)
Staff were so overwhelmed, Pat and John were left waiting for a ‘significant period’ of time after at least two nurses failed to return with a commode to allow Pat to go to the toilet.
John took matters into his own hands, wheeling his mother to a toilet himself.
But Pat soon stopped responding to his check-ins.
When staff entered the toilet, they found her slumped against the wall with dark fluid coming from her mouth.
She had no pulse.
Pat’s heart briefly started beating again after she received CPR, before stopping for second time once she was taken to another room.
This time nurses did not revive her after reading ‘Do Not Resuscitate’ on what they thought were her medical notes.
She died at 9.35pm from aspiration pneumonitis after inhaling stomach contents, which was caused by a small bowel obstruction, a post-mortem CT scan found.
But she shouldn’t have.
Staff had made a ‘catastrophic’ mistake, which John was informed of by a senior nurse while he sat with his dead mother.
Not only had nurses checked the notes of an entirely different patient, they had failed to check the NHS number on Pat’s wristband, the inquest heard.
They had not even confirmed her age and gender on the notes.
Pat worked in Rossendale and Burnley hospitals during her 30-year career (Picture: Lancs Live/MEN Media)
During an inquest at Accrington Town Hall, assistant coroner Kate Bisset said: ‘Unfortunately, tragically and catastrophically these were not Pat’s records.
‘They belonged to an entirely different patient who was male and in his 90s – characteristics which Pat very clearly did not share.
‘It was quickly realised that a DNR was not in place however, tragically, it was too late.’
Emergency consultant Dr Ahmad Alabood told the inquest it was an ‘honest mistake’ made before staff ‘were rushing’ in the ‘significantly over-stretched and over-crowded’ A&E department.
He admitted Pat would probably have been resuscitated had staff attempted to revive her, calling it ‘unfortunate’ they had not done so.
This elicited a retort from the coroner, who said: ‘Well it was beyond unfortunate wasn’t it. It was catastrophic.’
Bisset made a ruling of neglect and concluded Pat would not have died when she did if theses mistakes had not been made.
She said: ‘I am satisfied that Mrs Dawson would not have died, at that point, if the care she had received had been different.’
The coroner also flagged several areas of ‘sub-standard care’ Pat had received, including a failure to record any of the tests carried in the hospital, not following the sepsis and abdominal pathways, and checking the wrong patient’s notes.
Royal Blackburn Hospital has implemented several systemic changes since Pat’s death after an internal investigation flagged various concerns.
These include limiting the number of patients each nurses looks after to five.
DNR’s must also be reactivated every three months.
But John must live with the knowledge that ‘our mum will have been horrified by how the system she gave her life to failed her at her time of greatest need’.
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