A coroner says an ‘inexplicable delay’ at a hospital’s emergency department led to medics missing the opportunity to save a woman’s life.
Helen Smith Clark, 87, died at South Tyneside District Hospital on February 18 last year following complications after a fall.
She had been admitted two days before her death after falling outside her home in Poplar Drive, Whitburn.
South Tyneside coroner Terence Carney ruled Mrs Clark died after “a period of inexplicable delay”, with factors including only one nurse working on the minor injuries department, lack of beds on a ward she could have been transferred to, and the highest attendance of the year of patients at A&E.
He said the delay led to a deterioration in her condition, which should have seen her moved to a more acute area of the emergency department for more effective and intensive monitoring.
But when this was not done, he said it led to “a missed opportunity in seeking to avoid the untimely death of this lady”.
The failure in this instance to do so was a missed opportunity in seeking to avoid the untimely death of this lady.Terence Carney, South Tyneside Coroner
Hospital bosses say it was the “worst day of the year” with more people attending A&E than any other day and changes have been made to avoid a similar situation in future.
The inquest heard Mrs Clark died from multi-organ failure and bowel ischaemia, which is an inadequate blood flow, due to cardiac arrest due to ischaemic heart disease and chronic obstructive pulmonary disorder (COPD) and contributed to by the fracture of the pubis following a fall.
Mrs Clark was taken to the hospital, in Harton Lane, South Shields, by her daughter, Carol Young, after her fall.
They arrived at A&E at around 1.20pm and were seen by a nurse at 2.22pm before staff decided to move her to the minor injuries department to reduce her waiting time.
She was seen by a nurse at 4.05pm and sent for an X-ray, but wasn’t taken in until after 5pm.
The X-ray revealed two fractures to her pelvis.
Mrs Young told the inquest her mother became agitated when she needed the toilet and a nurse could not be found. She said she started feeling unwell and her oxygen levels fell.
Nurses decided to transfer Mrs Clark to a ward, but there were no beds available.
Mrs Young says her mother began to deteriorate.
She told the hearing: “She started to hallucinate and just wasn’t right, she was rambling.
“When the nurse came back my mam’s eyes were closed, she was rocking and looked dreadful and I started to think this was really bad.”
Mrs Young began phoning relatives and as she was contacting her brother, the doors of her mother’s room were “flung open” at around 9pm and doctors and nurses were running down the corridor with her.
Mrs Clark went into cardiac arrest and doctors spent more than 30 minutes working to bring her back to life.
She was taken to the intensive therapy unit (ITU) in an induced coma.
Mrs Clark’s kidneys and liver failed and she later passed away after two days at the unit.
Mrs Young said: “I just feel that if I’d been able to find a member of staff quicker when my mam needed the toilet she wouldn’t have become so distressed, or if she’d had a bed where she could have been monitored more closely, these events may not have unfolded.”
Giving a narrative finding, Mr Carney said: “Mrs Clark sustained a double fracture consequent on a minor mechanical fall, was hospitalised and then during a period of inexplicable delay sustained an acute deterioration, which could not have been predicted on her initial presentation, but once identified, should have resulted in transferring her to a more acute area of the emergency department for more effective and intensive monitoring.
“The failure in this instance to do so was a missed opportunity in seeking to avoid the untimely death of this lady.”
South Tyneside District Hospital bosses say changes had been made following the “difficult winter” during which Helen Smith Clark died.
Gareth Johnson, assistant clinical business manager of South Tyneside NHS Foundation Trust, said: “We all recognised it had been a difficult time in managing the patient flow throughout the ward at the hospital.
“As a department we recognised that we needed to review our procedures.”
He said February 16 had been the “worst day of the year” with more people attending A&E than any other day, but that measures had been put in place to ensure improvement.
The department was also understaffed with just one nurse to manage the minor injuries unit. He said they had made changes to staffing numbers and shift patterns as well as installing an electronic system to replace whiteboards, which supply doctors with patient information.
Dr Shaz Wahid, South Tyneside NHS Foundation Trust’s medical director, said: “We wish to extend our deepest sympathies to Mrs Clark’s family. On the day she came into A&E at South Tyneside District Hospital in February 2015, the department was very busy, with many patients requiring admission, and, unfortunately, we were unable to find her a bed as soon as we would have wished.
“Since last winter when our trust, like others up and down the country, came under severe, sustained demand on services, work has been ongoing in A&E to ensure we have the right support and teamwork between medical and nursing staff in the department, particularly at very busy times. As a result of measures which have been put in place, we have been able to improve performance in A&E, while maintaining patient safety and quality of care.”