A retired nurse died after hospital employees blended her up with a affected person on a ‘Do Not Resuscitate’ discover.
Pat Dawson, 73, was match and wholesome and had had no medical therapy in 30 years earlier than struggling a suspected bowel obstruction, her household advised an inquest.
The widow and grandmother was taken to Royal Blackburn Hospital by ambulance however died after she collapsed and employees stopped makes an attempt to resuscitate her following a have a look at ‘her’ notes.
By the time medics realised {that a} mix-up had left them studying a DNR report referring to a 90-year-old man, it was too late to avoid wasting her.
The inquest heard that employees didn’t verify the NHS quantity on Mrs Dawson’s wristband and even the gender and age on the notes.
Emergency advisor Ahmad Alabood known as the tragedy an ‘honest mistake because [staff] were rushing’ when the unit was ‘over-stretched and over-crowded’.
The inquest additionally heard particulars from an inside report by the hospital belief, 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 mentioned: ‘I am satisfied Mrs Dawson would not have died, at that point, if the care she had received had been different.’
She mentioned failings included the essential error in checking the mistaken affected person’s notes, failure to file checks that Mrs Dawson acquired in hospital and employees not following right sepsis and stomach care procedures.
Mrs Dawson’s son, John, advised 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 final 12 months, accompanied by her son, arriving earlier than 6pm at an ‘over-capacity’ A&E unit with greater than 90 sufferers ready to be seen.
She collapsed whereas in the bathroom, the inquest was advised. Mr Dawson had saved asking his mom by the door if she was OK however, receiving no response on a 3rd event, he known as for employees.
CPR was began by a healthcare assistant who was first on the scene, shortly leading to a return of circulation and Mrs Dawson, of Rawtenstall, was taken to a therapy room. But there her coronary heart stopped beating a second time.
Nurses then checked what they believed to be her notes and knowledgeable Mr Dawson that his mom had a ‘Do Not Resuscitate’ discover in place.
Mrs Dawson died at 9.35pm – lower than 4 hours after she had arrived on the hospital, the inquest heard.
But quickly afterwards, Mr Dawson was advised by a senior nurse that the DNR discover was meant for the 90-year-old man.
Ms Bisset mentioned: ‘Unfortunately, tragically and catastrophically these were not Pat’s information.
‘It was quickly realised that a DNR was not in place, however, tragically, it was too late.’
A autopsy CT scan discovered the reason for Mrs Dawson’s dying was aspiration pneumonitis after she inhaled abdomen contents.
The hospital mentioned the interior investigation resulted in a number of systemic modifications.
New procedures embrace limiting nurses to taking care of a most of 5 sufferers without delay and making certain DNR notices are reassessed each three months.
Jawad Husain, govt medical director and deputy chief govt at East Lancashire Hospitals, mentioned: ‘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 household.
‘The trust has reviewed all the learning from this case and has already implemented improvements.’
Mrs Dawson, who was a eager tennis and cricket fan, retired as an NHS major care nurse in 2016 after three many years of public service. She had two kids and one grandchild.
Source: www.perthnow.com.au
