Hospital bosses have apologised to the family of a woman who died after she was not seen by doctors for three days – because they didn’t know she was there.
Patricia Fowler, 75, was admitted to Blackpool Victoria Hospital with a broken arm but left on the cardiac ward because of a bed shortage.
An internal report into the incident, seen by The Gazette, reveals how the grandmother developed two deadly infections because an administrative error meant her name was left off the consultants’ list of patients.
By the time she was finally seen, Mrs Fowler, of Warren Street, Fleetwood, had developed pneumonia and sepsis, which caused her death two days later on January 15.
Her son, Scott, 38, today said: “This has devastated us. You don’t die from a broken arm. You die from pneumonia and sepsis, and she got those because she was left on that ward without doctors’ reviews. If she had been seen, or a nurse noticed she hadn’t been seen, she would still be here now.”
A spokesman for the trust which runs the hospital said lessons had been learned and passed on ‘sincere condolences and apologies’ to Mrs Fowler’s family.
Mrs Fowler, a retired widow whose husband Brian died in 2006, went to A&E on January 4 after falling, and was admitted to hospital.
She was discharged two days later with plans to attend a fracture clinic the following week, but was readmitted on January 9 after being referred back by her GP with hyponataemia – low sodium – and worsening back pain.
After being admitted to the Acute Medical Unit, she was transferred to Ward 39, a cardiac ward, shortly before 3am on January 10.
She was seen two days later in the fracture clinic, but not reviewed by a consultant until January 13, when she was seen following ‘an acute deterioration’, the hospital’s serious incident report (SUI) said.
It said: “At this time, blood tests showed deterioration in both kidney and liver function. The patient was then transferred to the Intensive Care Unit (ITU) with severe sepsis and placed on a ventilator.
“The patient’s observations while on the ward showed signs of deterioration, including low blood pressure, and impaired liver and kidney function. This deterioration does not appear to have been acted upon.”
Angela Russell, medical secretary in the Care of the Elderly department, said patients’ names were written on a white board in the bed managers’ office, before the patients were shared among the consultants.
At the end of November, the list started to be sent by email – possibly because the number of patients had increased, she said in a statement to Blackpool coroner Alan Wilson, who recorded a narrative conclusion.
The list contained names, but no hospital numbers, NHS numbers, or date of birth, she added.
“In this particular case there had been a patient with the same forename, which appeared in exactly the same place on the emailed list,” Ms Russell said.
“When going through the list, it was not obvious that the patient’s surname had changed. I did not notice this and neither did any of the Care of the Elderly consultants.”
One medic, Matthew Bowker, told the investigation there was ‘obviously no proper handover of care between medical shifts’, and said: “[Mrs Fowler’s] observations and blood tests during this period show warning signs of deterioration, including low blood pressure and impaired kidney and liver function, but this was not picked up on.
“It could be argued that had a proper timely review taken place, the severity of her deterioration could have been prevented, and she may have avoided admission to intensive care.”
Anaesthetist Dr Matthew Bowker said he expressed concerns after Mrs Fowler wasn’t ‘reviewed by a member of her medical team’ from the time she was moved on to the cardiac ward until three days later.
And Dr Anju Mirakhur described the confusion as to who was responsible for looking after her.
He said Mrs Fowler was assigned to the Care of the Elderly team but was not seen on January 10, 11, or 12, before several calls were made to doctors on the 13th, which meant she was seen at 2.50pm, 8pm, and 10pm.
She died two days later on January 15, with a post mortem examination ruling the course of death as sepsis, and pneumonia, with her broken arm a contributing factor.
A funeral service was held at Carleton Crematorium on Friday, February 5.
In a letter to Mr Fowler, of Dronsfield Road in Fleetwood, the hospital’s chief executive Wendy Swift apologised and said the internal investigation ‘identified where lessons can be learnt’.
She wrote: “I understand our solicitors have made a formal admission of liability in relation to the care afforded to your mother, which fell below a standard she could have reasonably expected to have received.
“I deeply regret the standard of care was inadequate on this occasion, and that as a result your mother passed away.
“I once again with to apologise unreservedly to you and your family, for the impact the failings have had, and will continue to have, on your lives.”
In a statement, the trust said: “Blackpool Teaching Hospitals NHS Foundation Trust has admitted liability in this matter and has passed on its sincere condolences and apologies to Mrs Fowler’s family.
“A full investigation was carried out into the circumstances of Mrs Fowler’s hospital journey and a number of changes have been implemented as a result of the findings of that investigation.”
It did not say what measures were specifically introduced to prevent a repeat, despite being asked by The Gazette.