Ex-nurse died after mix-up with DNR notice for man, 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, healthy and had had no medical treatment in 30 years before suffering a suspected bowel obstruction, an inquest heard.
The widow and grandmother was taken to Royal Blackburn Hospital in Lancashire – but died after collapsing when staff stopped attempts to revive her following a look at ‘her’ notes.
By the time medics realised a mix-up had left them reading a DNR report on a 90-year-old man, it was too late. The inquest heard staff failed to check the NHS number on her wristband or 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 ‘overstretched and overcrowded’. 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.’
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, 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. But soon afterwards, Mr Dawson was told by a nurse that the DNR notice was meant for the 90-year-old man.
The cause of death was aspiration pneumonitis after Mrs Dawson inhaled stomach contents.