'Life and death mix-up' Family's grief after former nurse died in A&E after staff read wrong 'Do Not Resuscitate' order
19 April 2024, 14:22 | Updated: 19 April 2024, 14:30
The family of a woman from Lancashire who died when hospital staff read the WRONG patient’s “do not resuscitate“ order say they fear the same mistake happening again.
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Retired nurse, Patricia Dawson, died at Royal Blackburn hospital last September - an inquest into her death highlighted a series of failings in her care at A&E.
The 73-year-old was fit and healthy, she’d been suffering with sickness and diarrhoea for a few days when she was taken to hospital with a suspected abdominal blockage.
When Mrs Dawson collapsed, staff stopped attempts to resuscitate her following a look at 'her' notes.
Tragically, a mix up meant staff were reading a DNR that belonged to a 91-year-old man.
By the time staff realised their mistake, it was too late, and Patricia had died.
Patricia’s son, John, had accompanied her to hospital, he says at no point did staff double check his mum’s name, gender or patient number. Soon after her death, a senior nurse told him about what had happened, he says it floored him:
“I was in a state of shock, I don’t think I said very much. You think you’d be absolutely livid; I was just stunned by it. How can you mix something up that means life and death and read the wrong person’s records?”.
When Mrs Dawson arrived at Royal Blackburn Hospital on 19th of September, she was greeted by an A&E department in chaos.
That afternoon it had been declared as over-capacity and over-stretched.
More than ninety patients were waiting to be seen. John describes seeing corridors filled with beds, nurses writing patients names on paper towels and confusion about what patients were where.
Mrs Dawson’s family say the pressure staff were under that night undoubtedly led to the series of failings that caused her death.
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John said: “There were too many patients and not enough staff.
“Patients don’t get seen quickly enough and mistakes happen when people are rushing and not focussing on what they’re doing, but you think even if the wrong notes had been handed over that there’d be a double check”.
“Whatever time you go into A&E, it’s overcapacity, you’ve got an eight hour wait at least. It isn’t a surprise that records are going missing or not being kept properly. We aren’t calling for people to lose their jobs, I do feel for the staff, everyone can see how much pressure they’re under, they aren’t given the backup and things need to change to prevent anything like this happening again”.
“My Mum served the NHS for thirty years and when it was her turn to get something back, she was failed by them”.
At an inquest in Accrington, heard she would have probably survived if medics had not checked the wrong documents.
The coroner ruled neglect and flagged several areas of ‘sub-standard care’ Pat had received, including a failure to record any of the tests carried in the hospital, not following the sepsis and abdominal pathways, and checking the wrong patient’s notes.
'Tragic incident'
In a statement Executive Medical Director and Deputy Chief Executive at East Lancashire Hospitals, Jawad Husain, said the Trust had fully cooperated with and accepted the verdict of the coroner.
"This is a tragic incident that should never have happened and for that we are truly sorry.
"We are grateful that the coroner recognised the difficult circumstances within our Emergency Department, as our team work so hard to provide care for all our patients.
“We know there is nothing we can say to lessen the pain felt by Mrs Dawson's family.
"The Trust has reviewed all the learning from this case, a number of improvements have been identified which have either already been implemented or in the final stages of implementation.”
