‘System failed her at time of greatest need’
Son’s statement is read out at the inquest into death of retired nurse
ARETIRED nurse who dedicated her life to the NHS was failed when she needed it most, her heartbroken son has said.
Medics left Pat Dawson from Rawtenstall to die and failed to attempt CPR after checking the wrong patient’s records on which a ‘Do Not Resuscitate’ form had been entered.
Those records belonged to a man in his 90s.
Pat, 73, had worked for more than 30 years as a nurse within the NHS.
She started at the nowclosed Rossendale General Hospital before spending several years at Burnley General Hospital and at a health hub in Rawtenstall.
She had been enjoying a well-earned retirement when she was rushed to Royal Blackburn Hospital on September 19 last year.
Her family described her as “fit and healthy”. She hadn’t been to visit her GP in more than three decades and had never gone to A&E before.
On that night, the accident and emergency department had been categorised as “over capacity and over-stretched” an hour before Pat arrived.
There were more than 90 patients waiting to be seen.
Accompanied by her son John, she was taken to the resus area as A&E buckled under overwhelming pressure.
Pat wasn’t seen by a single doctor and barely four hours later she would be dead.
An inquest heard on April 15 how the retired nurse who devoted her life to the NHS would probably have survived if medics hadn’t checked the wrong patient’s notes which had a ‘do not resuscitate’ order in place.
The court was told how Pat was taken to Royal Blackburn Hospital by ambulance with a suspected bowel obstruction on September 19.
As she waited to be seen she told John that she needed the toilet.
He asked four members of staff to help his mum get to the toilet but ended up wheeling her there himself after waiting for an hour.
John regularly asked his mum if she was ok but on asking a third time he received no response.
Staff then entered the toilet and found Pat slumped against the wall with dark fluid coming out of her mouth.
A healthcare assistant was first on the scene and, after noting Pat had no pulse, CPR was started which quickly resulted in a return of spontaneous circulation.
Pat, who was born in Salford and lived in Rawtenstall, was then taken into a room but her heart stopped beating a second time.
Nurses went to check the notes and returned to inform John that she had a ‘Do Not Resuscitate’ in place and she passed away at 9.35pm.
As John sat with his mother after she had been pronounced dead, he was visited by a senior nurse who informed him of the mistake.
The inquest, at Accrington Town Hall, heard the patient whose notes were confused for Pat’s was a 90-year-old man.
Assistant Coroner Kate Bisset highlighted the overwhelming pressure on A&E departments across the UK as well as listing a raft of failings which meant that Pat died when she did.
She also ruled that, had medics attempted to resuscitate Pat, she would probably have survived.
“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,” Assistant Coroner Kate Bisset said.
“It was quickly realised that a DNR was not in place however, tragically, it was too late.” The inquest heard that staff had failed to check the NHS number on Pat’s wristband or even by confirming the gender and age on the notes.
Natalie Cole, who was part of the team which conducted an internal investigation following Pat’s death, said: “It’s such a basic thing to do in the heat of the moment... they had just not done it.”
“It’s almost bread and butter that it should have happened,” Assistant Coroner Kate Bisset added.
Giving evidence to the inquest, emergency consultant Dr Ahmad Alabood said it had been an “honest mistake because [staff] were rushing”.
Dr Alabood said that, when Pat was brought into A&E, the department was “significantly overstretched and overcrowded”.
All eight bays in resus were full and each nurse had an unlimited number of patients to look after.
This week John was accompanied to an inquest into his mum’s death by his wife Paula and his sister Karen and several other relatives and family friends.
In his statement read out during the inquest, John from Rossendale said: “I know that our mum will have been horrified by how the system she gave her life to failed her at her time of greatest need.
“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.
“We understand the pressure on the NHS but what we cannot forgive is that not one person who was involved thought to check mum’s records. Was 10 seconds too much to ask?”
Pat’s daughter Karen said during the inquest her mum “would have received better care if she’d stayed in the ambulance”.
Pat’s daughter-in-law Paula said the family in no way intended to conduct a “witch hunt” against hospital staff.
“We want to stress that we know it’s not one person’s failings, it’s the whole system that is failing, not only us but you guys as a team as well,” she added.
Dr Alabood, who admitted that it is probable that Pat would have been resuscitated had medics attempted to do so, was asked by the coroner if there was anything else he wanted to say regarding Pat’s admission to A&E to which he replied: “It was unfortunate”.
The coroner then interjected: “Well it was beyond unfortunate wasn’t it. It was catastrophic.”
Dr Alabood expressed his “deepest sympathy and condolences” to Pat’s family and said he was “so very, very sorry”.
The inquest heard that as John left the hospital he bumped into the paramedic who had brought his mum in.
John informed the paramedic that Pat had died.
“He was totally stunned; he couldn’t believe she had died,” John said.
Several systemic changes have been implemented since Pat’s death after concerns were highlighted during an internal investigation.
These include limiting the number of patients each nurse looks after to five and reactivating a DNR every three months.
A post mortem CT scan confirmed the cause of Pat’s death was aspiration pneumonitis after she inhaled stomach contents.
This was caused by a small bowel obstruction.
Returning a narrative conclusion, the coroner flagged up several areas of “sub-standard care” which Pat had received including a failure to record any of the tests carried out in hospital, not
following the sepsis and abdominal pathways and the error in checking the wrong patient’s notes.
The coroner concluded that Pat would not have died when she did had it not been for the mistakes and, significantly, made a ruling of neglect.
She added: “I am satisfied that Mrs Dawson would not have died, at that point, if the care she had received had been different.”
The inquest also heard that one member of staff who had been directly involved in Pat’s care later resigned due to being “traumatised” by what had happened.
A&E departments across the country are running at full capacity with many pleading with patients to consider calling 111 or visiting an urgent treatment centre before heading to hospital.
This week bosses at East Lancashire Hospitals NHS Foundation Trust, which runs Blackburn Hospital, confirmed an investigation had been launched following the deaths of two patients who were waiting to be seen in A&E.
On average 30 patients wait on the A&E corridor while 14 patients are in resus and 24 people are based on the main hospital corridor.
During the inquest into Pat’s death, hospital bosses admitted that they cannot rule out a patient dying in similar circumstances.
The investigation report concluded: “Given the relentless pressure on A&E departments the investigation is concerned that a similar event could occur in the future.”