Rawtenstall woman not resuscitated after cardiac arrest

An inquest found there were “multiple failings” in the care of Patricia Dawson, 73, from the time she arrived at the hospital until her death later on the same day.

Patricia, a retired nurse from Rawtenstall who served in the NHS for more than 30 years, ultimately died from aspiration pneumonitis (food or fluid entering the lungs) caused by a blockage in her bowel, which was contributed to by atheromatous disease (narrowed arteries).

Patricia's family said she loved going on holidays (Image: Paula Dawson)

Coroner Kate Bisset, sitting at Accrington Town Hall, found the care Patricia received at Royal Blackburn Hospital was not as it should have been, and she should have been started on both the sepsis and abdominal pain pathways.

A family statement read at the beginning of the inquest said Patricia was devoted to her family and would do anything to help them.

She had previously been in excellent health and was not ever known to have been ill.

She loved holidays and travelling to see family in Devon, and was on an 18-year streak of attending The Wimbledon Championships with her best friend.

Patricia was born in Salford and lived in Rawtenstall (Image: Paula Dawson)

On Tuesday, September 19, Patricia’s son, John, received a message at around 3.20pm to say she was not feeling well, and when he called in after work he found Patricia half on and half off the bed and writhing in discomfort.

An ambulance arrived at 4.50pm to take her to Royal Blackburn, where staff were passed over a message from the paramedic to say there was a possible stomach blockage.

Student nurses took blood samples from Patricia and another nurse came in asking where her notes were.

In John’s evidence, read into the record by Ms Bisset, he said different members of staff were walking around the ward asking where people were and there were no obvious recordings of where people were located.

He added he saw a nurse writing down names on a paper towel.

It was also submitted Patricia was made to wait around three hours for a commode before eventually being given a wheelchair so she could be pushed to the toilet.

John waited outside and called for help when he did not hear Patricia respond.

A doctor came to check her pulse and said she had stopped breathing, however, she was resuscitated after around 30 seconds of chest compressions.

However, Patricia soon suffered a second cardiac arrest, during which no attempt was made to resuscitate her.

The inquest heard this was due to staff checking a different patient’s notes, that of a 90-year-old man, who had a Do Not Resuscitate (DNR) marker on his files.

Because of this, staff thought Patricia had directed she did not wish to be resuscitated when this was not correct.

Ms Bisset found Patricia’s death was contributed to by neglect, in not checking her identity matched the identity of the patient with the DNR order in place.

Patricia worked for the NHS for more than 30 years (Image: Paula Dawson)

Dr Ahmad Alabood, a consultant in emergency medicine at the hospital, said there had been an “honest error” in the confusion between Patricia and the other patient, and it happened “in the heat of the moment” when a healthcare assistant passed on the wrong notes.

A Patient Safety Incident Investigation was undertaken and found the ward was overcapacity at the time of Patricia’s arrival with 94 patients, and this fluctuated between 90 and 100 patients during her stay.

Ms Bisset said she was satisfied the trust was taking the matter seriously and did not issue a report.

Offering a narrative conclusion, she said: “Patricia Mary Dawson died on September 19, 2023, at the Royal Blackburn Hospital.

"She had been taken to hospital by ambulance due to abdominal pain and arrived at A&E which was overcapacity.

“Prior to being seen by a doctor, Mrs Dawson suffered a cardiac arrest from which she was resuscitated.

"However, Mrs Dawson suffered a second cardiac arrest, during which no attempt was made to resuscitate her.

“This was due to staff checking a different patient’s notes and believing that Mrs Dawson had directed that she did not wish to be resuscitated when this was not correct.

"The other patient had a DNR order on their records, Mrs Dawson did not.

“Mrs Dawson’s death was contributed to by neglect in not checking her identity matched the identity of the patient with the do not resuscitate order in place.

“Mrs Dawson’s experience is every patient’s worst nightmare. She had diligently served the NHS for 30 years and no doubt believed in everything it stood for.

"The pressure on emergency departments is well known locally and nationally but in her case, a failure to apply first principles and basic care meant her loved ones watched as she died surrounded by doctors with no one helping.

“Her death is a timely and traumatic reminder to never take for granted information which would have taken seconds to check.”

Patricia devoted her life to her family (Image: Paula Dawson)

A family statement sent by Paula Dawson, Patricia's daughter in law, said: "Patricia was devoted to her family. She would do anything to help in any way - the characteristics of a long-serving, hard-working, caring NHS nurse.

"Pat's nursing career lasted more than 30 years. It's because of this we know our mum would have been horrified by how the system she had given most of her adult life to failed her at her greatest time of need.

"It's catastrophic how she was failed, not by one individual, but by the whole NHS trust.

"We are in no doubt that she was ill that evening but we believe that had she received the correct care, been put on the correct pathways, and been treated in accordance with the hospital policy, she would be with us today.

"Life will not be the same without our mum, who was also a nanna, sister, and much-loved friend to many, and nothing will bring her back, but we would be failing as a family if we didn't highlight how much room for improvement there is at Royal Blackburn Hospital A&E, and we hope that lessons will be learned and our mum won't have died in vain.

"We would also like to thank the North West Ambulance Service for getting her diagnosis right and for treating her with the correct care she deserved."