Grandmother bled to death after routine gallbladder operation because nurses were too busy to check on her for 16 hours
- Susan Wilson went to Nottingham's Queens Medical Centre for procedure
- Observations on care worker should have been carried out every four hours
- Nurse failed to carry out checks because he was busy with other patients
- Miss Wilson suffered a massive heart attack as a result of severe bleeding
- Coroner said staffing was a national crisis that needed to be addressed
Susan Wilson was found dead in her hospital bed hours after she was last checked
A grandmother who went to hospital for a simple gallbladder operation was left to 'bleed to death' on a ward for 16 hours because staff were too busy, an inquest heard.
Susan Wilson, 59, was admitted to Nottingham's Queens Medical Centre for the routine procedure on October 18 last year.
The retired care worker spent time on a high-dependency unit before being moved to another ward where observations should have been carried out on a four-hour basis.
But a nurse at the hospital failed to carry out the basic checks and Miss Wilson suffered a massive heart attack as a result of severe bleeding on October 19.
Yesterday an inquest at Nottingham Coroner's Court was told the mother-of-one could have been lying dead on the hospital ward for several hours.
Staff nurse Neil Bailey told the hearing he was too busy on his shift to check on Miss Wilson and admitted her requirements were overlooked.
Giving evidence he said: 'At no point did I make a conscious decision not to attend to Susan.
'When I handed over my patients (at the end of my shift), I became aware I had entirely overlooked Susan‚Äôs needs and requirements and went to check her and it was at that time I discovered no signs of life.'
The hearing at Nottingham Council House heard how staffing concerns had been previously raised on the E18 ward, where Mrs Wilson died.
The nurse had been caring for ten of the 28 patients on the ward at the time.
However, the inquest heard how there were 'too many unknowns' to say whether her death would have been avoided as Mrs Wilson had an existing heart problem.
Nottingham Deputy Coroner Heidi Connor criticised the treatment and described the situation as 'shocking'.
Recording a narrative verdict the coroner said staffing was a national crisis that needed to be addressed.
She said: 'It goes without saying this is something the trust needs to prioritise to avoid tragedies like the one we have heard about today.
Nottingham Deputy Coroner Heidi Connor criticised the hospital's treatment and described the situation as 'shocking'
'To miss or delay one observation is one thing but to have no observations in an entire 12-hour shift and no notes at all is nothing short of shocking.
'It‚Äôs clear he (Mr Bailey) felt overwhelmed and I have some sympathy in that respect.
'Staff Nurse Bailey failed to provide the medical attention Susan needed.'
After the hearing her partner of six years Stuart Clift, 66, said he believed her death could have been avoided.
The retired care worker said: 'We were angry and appalled at the treatment Sue received, the hospital should have done better.
'I think on the the balance of probability she would have survived if treated properly.
'I was extremely shocked to find out what happened to Sue, the hospital didn‚Äôt tell me, they did say she had suffered a heart attack which was true and believable as she had a heart condition.
'Although, what they failed to mention was she was left for almost a full day.
'I only found this out and what really happened in January when I received the medical reports. I was deeply upset, as was the whole family.
A CATALOGUE OF FAILURES: HOW NHS WARDS HAVE FAILED PATIENTS
A diabetic grandmother went up to three days without receiving insulin injections and died as the result of multiple failings by hospital staff, a coroner ruled this week. Sheila Hibbert, 77, was admitted to Bradford Royal Infirmary where staff failed to check her blood sugar levels or give her prescribed treatments for up to nine hours. The grandmother went an additional 24 hours without receiving any medication as the hospital failed to notify her district nurse when she was discharged. By the time Mrs Hibbert's nurse arrived at her home, the pensioner's blood sugar levels were considerably high. She was taken to hospital, where she was diagnosed with diabetic ketoacidosis, a dangerous complication caused by lack of insulin. The pensioner, who was also undergoing chemotherapy for endometrial cancer, died from multiple organ failure on February 6, just a week after being admitted to Bradford Royal Infirmary.¬†
A gifted student died from anorexia at 19 after a string of failings by GPs and specialists. When Averil Hart died it is thought her weight had dropped to below six stone. Averil's family say she was supposed to have been in the care of specialist medical staff while she studied at the University of East Anglia in Norwich. But she was placed under the care of a junior trainee psychologist who had no experience of anorexia, her parents claim. After realising she had lost weight her family called her previous doctor who promised to send a NHS specialist to check on her. But nothing was done and a few weeks later she was found unconscious. She slipped into a coma and died on December 15, 2012. The NHS trusts in charge of Averil‚Äôs care offered their ‚Äėsincerest apologies‚Äô and said a formal investigation had been launched.
A patient bled to death following the 'gross failure' of a doctor to give her a life-saving blood transfusion before it was too late. Andrea Green, 42, died 14 hours after a routine operation for back pain, which may have been unnecessary, an inquest heard. Consultant surgeon Hany Ismaiel accidentally cut an artery during the operation and staff at Barnsley District Hospital failed to pick up on subsequent internal bleeding. Locum senior house officer Dr Oluwatosin Taiwo, who trained in Nigeria, failed to act 'promptly and efficiently' to give her a transfusion, according to a coroner. The medic knew Miss Green had suffered a ‚Äėmassive blood loss‚Äô but instead of giving her the transfusion when blood became ready he called for more tests. In delivering her findings, assistant Sheffield coroner Siobhan Kelly said: ‚ÄėIt was a gross failure of basic medical attention for the doctor not to ensure the blood transfusion took place as soon as possible after the blood was ready. Had he done so Andrea Green would have lived.‚Äô In her verdict, Ms Kelly said neglect contributed to Miss Green‚Äôs death at Barnsley District Hospital on March 13 2010 in that the transfusion should have been given more quickly.
'No-one should have had to go through what Sue went through, she was a bubbly person who loved her work as a care worker before she retired through ill-health.
'She was gregarious, she wasn‚Äôt frightened to approach people, to be friends with them, she would get involved with people, she really enjoy mixing and was a keen gardener.
'I think that makes it even worse, the fact that she wasn‚Äôt a shy person who would usually sit back and not say anything if something wasn‚Äôt okay.
'However, 30 hours after the operation she was dead - they simply didn‚Äôt monitor her properly.
'The hospital have apologised but I feel Mr Bailey could have done more.'
Paul Sankey, clinical negligence lawyer with law firm Slater and Gordon, added: 'Susan Wilson‚Äôs tragic death was wholly avoidable.
'She was left to bleed to death on a ward and no one noticed.
'After 16 hours on a ward, none of her four-hourly observations had been done.
'Had nurses checked her vital signs, they would have realised that she was deteriorating, infused blood and returned her to the high-dependency unit.
'She would not have died. The nursing care she received was inadequate and there were too few staff on the ward.
'The Care Quality Commission has raised concerns about staffing levels at Queen‚Äôs Medical Centre and the trust running the hospital need to take note.'
Jenny Leggott, director of nursing and midwifery for Nottingham University Hospitals Trust, yesterday issued an apology to the family.
She said 'We extend our condolences and reiterate our apology to the family for failing our basic duties of care and letting Mrs Wilson and them down so badly.
'The absence of regular clinical observations and checks on Mrs Wilson overnight when she passed away meant her deteriorating condition regrettably went unnoticed.
'We have learnt from this tragic case and made changes to improve safety and outcomes for our future patients.'
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