Mum died after hospital staff checked 'do not resuscitate' notice of the wrong patient

  • ITV Granada Reports journalist Emma Sweeney was at the inquest

The heartbroken son of a retired nurse has said she "dedicated her life to the NHS" and "failed when she needed it most".

Pat Dawson died after medical staff at hospital in Blackburn used the wrong notes which requested the patient should not be resuscitated if they were seriously unwell.

Staff stopped giving the 73-year-old CPR which resulted in her death.

At an inquest in Accrington, heard she would have probably survived if medics had not checked the wrong documents.

Area Coroner, Kate Bisset, said : "I am satisfied that Mrs Dawson would not have died, at that point, if the care she had received had been different."

Pat's family described her as "fit and healthy", saying she had not been to visit her GP in more than three decades and never visited A&E.

Her son, John, said: "Not once in the last 30 years had mum personally sought any kind of emergency NHS care, that is until the tragic circumstances we have re-lived here today.

"And tragic is truly what it is. It is beyond belief quite how catastrophically she was failed not by one individual but by the NHS trust.

"Life will not be the same without mum and we cannot bring her back, but we would be failing as a family if we didn't highlight how much room for improvement there is at the Royal Blackburn Hospital emergency department."

Pat Dawson was described as "devoted" to her family. Credit: Paula Dawson

Pat was taken to hospital by ambulance with a suspected bowel obstruction on 19 September last year, the court heard.

That night, the accident and emergency department had been categorised as "over capacity and over-stretched" an hour before she arrived with John.

There were more than 90 patients waiting to be seen, the inquest was told.

As John sat with his mother after she had been pronounced dead he was visited by a senior nurse who informed him of the mistake.

The inquest heard that the patient whose notes were confused for Pat's was a 90-year-old man.

"Unfortunately, tragically and catastrophically these were not Pat's records; they belonged to an entirely different patient who was male and in his 90s; characteristics which Pat very clearly did not share," Ms Bisset said.

"It was quickly realised that a DNR was not in place however, tragically, it was too late."

The inquest heard that staff had failed to check the NHS number on Pat's wristband or even by confirming the gender and age on the notes.

Giving evidence to the inquest, emergency consultant Dr Ahmad Alabood said it had been an "honest mistake because [staff] were rushing".

Dr Alabood said that, when Pat was brought into A&E, the department was 'significantly over-stretched and over-crowded'.

All eight bays in resus were full and each nurse had an unlimited number of patients to look after.

Dr Alabood admitted that it is probable that Pat would have been resuscitated had medics attempted to do so.

In his statement read out during the inquest, Pat's son John said: "I know that our mum will have been horrified by how the system she gave her life to failed her at her time of greatest need.

"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 Royal Blackburn Hospital said several systemic changes have been implemented since Pat's death and after an internal investigation.

These include limiting the number of patients each nurse looks after to five and reactivating a DNR every three months.

A post mortem CT scan confirmed the cause of Pat's death was aspiration pneumonitis after she inhaled stomach contents which was caused by a small bowel obstruction.

Returning a narrative conclusion, the coroner flagged up several areas of "sub-standard care" which Pat had received including a failure to record any of the tests carried out in hospital, not following the sepsis and abdominal pathways and the error in checking the wrong patient's notes.

The coroner concluded that Pat would not have died when she did had it not been for the mistakes and, significantly, made a ruling of neglect.

Want more on the issues affecting the North? Our podcast, From the North answers the questions that matter to our region.