Family’s anguish after dad’s death hastened by hospital mistakes
ASEVERELY underweight Ormskirk man who died from a chest infection picked up in hospital was mistakenly not referred to a dietician until 12 days after admission.
Philip Gough, 86, suffered a hip fracture after falling unexpectedly at the home of his daughter, Christina Howes, but, instead of recovering as expected, he steadily deteriorated until he died of severe bilateral pneumonia on May 29, 31 days after his admission.
Despite his very low weight, Mr Gough was described as very fit for his age and still lived at home with his son, Phil, until his admission.
But during his stay in Southport Hospital, he began to suffer from confusion, a symptom which worsened as he contracted the deadly infection.
An inquest into his death was held at Southport Town Hall on Tuesday, with coroner Graham Jackson concluding that lack of nutrition while in hospital, along with the widower’s age and general health, probably contributed to the speed of his death.
Mr Jackson gave a narrative verdict for the former kitchen fitter’s death, and pinpointed some shortcomings in his care.
In a statement released after the inquest, his family said that it was hard to describe the pain of learning his death was potentially hastened in this way.
Southport and Ormskirk NHS Trust has now invited the family to meet and discuss their concerns over his treatment.
Mr Gough’s four children – Christine, Phil, Jim and Mark – filed an official complaint with the trust over his treatment last year, a decision which ultimately led to the inquest being held one year after his death.
The family say they never expected his hospital stay to be a lengthy one, or even a cause for major concern, but they were shocked and heartbroken as his health quickly deteriorated and he stopped recognising those around him.
Jim said: “It was very upsetting.
“My dad was a stranger to us. He was not making any sense and we could not understand how such a dramatic change could have happened.
“From that point on, Dad never fully recovered his faculties and was often hallucinatory and mentally disturbed.” Giving evidence at the inquest, dietician Jennifer Moffat said that Mr Gough was referred for help from her department several days after his first admission.
Bu t , based on his weight and nutritional habits, he should have been referred when he first arrived. Errors in filling in a paper assessment and separate electronic version meant that the dieticians were not contacted at the first instance.
Further difficulties in fitting a nasal feeding tube also meant that Mr Gough went up to a further 48 hours without any nutrition other than an IV drip.
Dr Sharma, who carried out the post mortem examination, said that while malnutrition was not classed as one of the causes of Mr Gough’s death, it was a factor that would have made him more susceptible to picking up an infection.
Ms Moffat added that such problems were known to exist in Southport and that the hospital trust was working on ways to eradicate instances such as this in the future.
Mr Gough’s family said in a statement: “The coro-
It’s hard to describe how much more pain that brings, knowing his death was hastened
MR GOUGH’S FAMILY ner said id our f father’s th ’d death th was probably accelerated by a lack of nutrition.
“It’s hard to describe how much more pain that brings knowing that his death was hastened in that way.
“It became apparent at this hearing that our father did not have the correct t nutrition t iti at th hospii tal for at least 12 days. When he was admitted he should immediately have been referred to dieticians. This was not done.
“The fact that a dietician in evidence said a lack of nutrition made our father more susceptible to infections and the pathol- ogist it said id malnutrition l t iti made him more predisposed to pneumonia makes our distress more painful.
“He did, after all, die of pneumonia which he caught at that hospital.
Juliette Cosgrove, director of nursing, midwifery and therapies, said: “As t the trust’s new director of n nursing, I have offered Mr G Gough’s family a meeting with me to discuss any remaining concerns they m may have about his care.
“We always seek to understand where we can make improvements to the care of our patients and share this with our staff.
“I would also like to take this opportunity to send his family my sympathy and sincere condolences on their loss.”