Ex-nurse died after hospital staff mixed up her notes with Do Not Resuscitate notice of man age 90
A RETIRED nurse died after hospital staff mixed her up with a patient on a ‘ Do Not Resuscitate’ notice.
Pat Dawson, 73, was fit and healthy and had had no medical treatment in 30 years before suffering a suspected bowel obstruction, her family told an inquest.
The widow and grandmother was taken to Royal Blackburn Hospital by ambulance but died after she collapsed and staff stopped attempts to resuscitate her following a look at ‘her’ notes.
By the time medics realised that a mix-up had left them reading a DNR report relating to a 90-year-old man, it was too late to save her.
The inquest heard that staff failed to check the NHS number on Mrs Dawson’s wristband or even the gender and age on the notes.
Emergency consultant Ahmad Alabood called the tragedy an ‘honest mistake because [staff] were rushing’ when the unit was ‘ over- stretched and over-crowded’.
The inquest also heard details from an internal report by the hospital trust, which warned: ‘ Given the relentless pressure on A&E departments, the investigation is concerned that a similar event could occur in the future.’
In her narrative conclusion this week, coroner Kate Bisset said: ‘I am satisfied Mrs Dawson would not have died, at that point, if the care she had received had been different.’
She said failings included the crucial error in checking the wrong patient’s notes, failure to record tests that Mrs Dawson received in hospital and staff not following correct sepsis and abdominal care procedures.
Mrs Dawson’s son, John, told the inquest in Accrington: ‘I know that our mum would have been horrified by how the system she gave her life to failed her. 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.’
The inquest heard that Mrs Dawson was taken to hospital on September 19 last year, accompanied by her son, arriving before 6pm at an ‘ over- capacity’ A&E unit with more than 90 patients waiting to be seen. She collapsed while in the toilet, the inquest was told. Mr Dawson had kept asking his mother through the door if she was OK but, receiving no response on a third occasion, he called for staff.
CPR was started by a healthcare assistant who was first on the scene, quickly resulting in a return of circulation and Mrs Dawson, of Rawtenstall, was taken to a treatment room. But there her heart stopped beating a second time.
Nurses then checked what they believed to be her notes and informed Mr Dawson that his mother had a ‘Do Not Resuscitate’ notice in place.
Mrs Dawson died at 9.35pm – less than four hours after she had arrived at the hospital, the inquest heard.
But soon afterwards, Mr Dawson was told by a senior nurse that the DNR notice was meant for the 90-year-old man. Ms Bisset said: ‘Unfortunately, tragically and catastrophically these were not Pat’s records.
‘It was quickly realised that a DNR was not in place, however, tragically, it was too late.’
A post-mortem CT scan found the cause of Mrs Dawson’s death was aspiration pneumonitis after she inhaled stomach contents.
The hospital said the internal investigation resulted in several systemic changes.
New procedures include limiting nurses to looking after a maximum of five patients at once and ensuring DNR notices are reassessed every three months.
Jawad Husain, executive medical director and deputy chief executive at East Lancashire Hospitals, said: ‘This is a tragic incident that should never have happened and for that we are truly sorry.
‘We know there is nothing we can say to lessen the pain felt by Mrs Dawson’s family. The trust has reviewed all the learning from this case and has already implemented improvements.’
Mrs Dawson, who was a keen tennis and cricket fan, retired as an NHS primary care nurse in 2016 after three decades of public service. She had two children and one grandchild.
‘Catastrophic and tragic’