Inquest finds that hospital death was in part contributed to by systemic neglect

Monday 17 September 2018

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The Deceased was 90 years of age. On the 22 January 2018, she was admitted to Ward 22 in Arrowe Park Hospital from the Accident and Emergency Department after presenting with a ten-day history of headaches with associated vomiting. Up until then she had had a fit and sprightly life.

A decision was made to feed the deceased via a Percutaneous Endoscopic Gastrostomy (PEG), which was inserted on 9 February 2018 with no complications. She was to be fed at a rate of 100ml/hour over fifteen hours with a nine-hour rest.

The 12 February 2018, ward 22 was very busy to the extent that there was one member of nursing down and a nurse had to manage twelve patients rather than the usual ratio of eight to ten patients. This was an acute ward for the elderly with diverse presentations. The Deceased was categorized for nursing as low risk, whereas other patients had high and moderate risk classifications. The higher the risk category the greater the demand on nursing input and observations.

There was demand for beds from the emergency department and there was a management culture concentrating on patient flow without due regard to a safe nursing environment. The ward manger flagged up concerns to management with regard to trying to reduce pressure on the ward from the bed managers - Silver Command. The court found there was an opportunity to improve the environment for safer nursing on the ward, but this was not taken. This was a serious failure in part created by an environment for nursing errors. This gross systemic basic failure in part more than minimally, negligibly or trivially caused or contributed to the death.

At 12.00 on 12 February 2018, The deceased’s PEG feed was commenced by a Registered Nurse. The feed was started at 400ml/hour to accelerate the feed through the tubing to the PEG site. The Nurse intended to then start the feed as per prescription of 100ml/hour to be administered over a period of fifteen hours. At 17.00 the nurse became aware that the deceased had vomited and noticed that her feed had gone through over a five hour period instead of fifteen. It is found that the nurse was attending other patients' needs in her section due to the extreme unprecedented patient demand and she had inadvertently been occupied such that she did not have an opportunity to correct the feed rate. The court found this was an error but not of her making and not one which she could have avoided in the unsafe nursing environment she was placed..

An emergency call was made at approximately 06:15am on 13 February, however, the deceased’s early warning score was noted to be 12. A chest x-ray showed a new bi-basal patchy consolidation and intravenous antibiotics and fluids were commenced.

A further emergency call was made at 07:48am, as the deceased’s early warning score was 10, escalating to 15. The medical impression was sepsis due to likely aspiration. It was agreed that her presentation was irretrievable and she should be treated conservatively. Treatment continued with antibiotics and fluids.

Despite active treatment, there was no improvement in the deceased’s condition.

She passed away on 17 February 2018 at 15:30.

The coroner concluded that this was an accidental death in part contributed to by systemic neglect.

Ifeanyi Odogwu was instructed by Leanne Devine of Broudie Jackson Canter Solicitors.


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