Coroner probes Harlow hospital death
In November, an Inquest was held at Chelmsford Coroner's Court into the untimely death earlier last year of a female patient at the Princess Alexandra Hospital in Harlow. When the 71-year-old patient, Barbara O'Brien, was admitted to hospital the previous January she was suffering from pneumonia but assessed as being at a low (3%) risk of death from the condition.
When Barbara’s observations deteriorated, staff failed to comply with the National Early Warning Score (NEWS) protocol for acutely-ill patients. They did not note her worsening hypoxia and escalate care to a senior nurse or doctor as NEWS would have required.
When a patient’s vital signs are outside normal parameters, depending on the actual score, staff must take action or involve a doctor. In this case, staff either failed to calculate the score correctly or did not respond adequately to an accurate score.
In the absence of the medical response she needed, the patient’s condition worsened, and her deterioration went undetected and untreated. On the day prior to her death there had been a 15 hour delay in her being reviewed by the doctor which the Trust have admitted was ‘unacceptable’. Five days after her admission to hospital, she sadly suffered a fatal cardiac arrest.
An investigation following Barbara O’Brien’s death concluded that, had staff responded appropriately and she had been reviewed earlier, there would have been a good possibility of her surviving the episode of pneumonia.
Among the factors contributing to the outcome were: poor and inaccurate assessment of the patient by the nursing staff; failure to seek input from more senior medical staff; and non-compliance with the NEWS protocol and escalation process.
The Coroner concluded that due to the miscalculation of the NEWS score, appropriate action was not taken and even when it was calculated correctly, there was no escalation which led to a ‘missed opportunity’ to save Barbara.
Acting for the deceased’s daughter, Attwaters Jameson Hill commented: “The failures in the care afforded to Mrs O’Brien were unacceptable and this was reflected throughout the Inquest process. Her family thought she was in the best place and never once thought that she was being so badly let down by the professionals in whom they had put their trust.
“What makes it even worse is that her family never had the opportunity to say goodbye to her, because no one had taken any notice of the deterioration and warned the family of this.”
Barbara O’Brien’s daughter Sharon added: “We are pleased that the Coroner recognised the failings of the hospital. What saddens us greatly is that during the inexplicable 15 hour delay waiting to be seen by a doctor, my mum was left feeling that they didn’t care. The hospital’s failure to act upon her deteriorating condition meant that no one was called, not even her family, thus she was left without any help to die alone, without the comfort of those she loved.”