Coroner finds death of woman with learning disability was result of 'gross failures'

The family of a women with learning disabilities who died at a Hertfordshire hospital have said they feel let down by the hospital after a coroner ruled that her death was the result of ‘gross failures’ by nursing staff.

Eileen Smith was admitted to Lister Hospital in Stevenage for overnight monitoring and medical care following vomiting and a shortness of breath.

But despite staff identifying that she needed urgent assessment, a series of errors – including nurses sending messages to the wrong pagers, and a failure to included details of her case in shift handover documents - meant that the doctors on duty were not aware of her deteriorating condition.

With no additional calls for help made during the night, it wasn’t until a doctor responded to an emergency call just after 0500 in the morning that action was taken; but by then it was too late, and just two days after she was admitted to the hospital Eileen died having suffered a cardiac arrest.

Faecal peritonitis, perforated small bowel and pseudo intestinal obstruction were reported as the cause of death.

Coroner Edward Thomas recorded a narrative verdict. In his findings he voiced his concerns that the purple folder – carried by all vulnerable people which contains information about their medical history – was not properly reviewed on Eileen’s admission.

He said: “…what is the point of having a purple folder with all the details of that person’s disability without studying it carefully and being able to assess the patient in the light of the information contained therein. The learning disability protocol supplied to the inquest also confirmed the importance of the information from carers and I feel there was also a failure not to contact either the home or Eileen’s niece …”

Lesley and Keith Dean

Eileen's niece Lesley Dean, said: "The chart clearly showed her deterioration but nothing was done. The hospital has admitted that someone should have been called.

"It felt like they tried a couple of times and then just left it. I feel really let down by the care Eileen received and she is greatly missed. "She had a lot of friends and they miss her.

"Eileen was always happy. You couldn't have a conversation with her really but she was always smiling and laughing." The family's solicitor

Merry Varney from the human rights team at Leigh Day, said: “The coroner's conclusion recognises that multiple failings in Eileen's care contributed to the cause of her death and that had these not occurred, her death may have been prevented.

“Eileen, due to her learning disability, was unable to communicate that she was in distress and needed adjustments to be made to help her comply with the medical treatment she needed.

“Despite observations showing a deterioration in her health, it appears her silence was taken as a sign she was okay and no steps were taken over a 12-hour period to seek further medical attention for her despite it being obvious she was not receiving treatment her doctor had prescribed.”

The move also follows a serious case review by the Trust which found that Eileen’s death was the result of failing to ‘appropriately escalate a deteriorating patient’.

Following the inquest a spokesman for the East and North Hants NHS Trust, which runs the Lister Hospital, apologised to the family and committed to ‘reviewing very carefully the Coroner's very detailed conclusions’ that they have now received.

The hospital also announced that it had begun to pilot a new electronic observation system at the Stevenage hospital that will raise the alarm if a patient’s condition starts to deteriorate.

Jan Tregelles, chief executive at Mencap, said:

“1,200 people with a learning disability are dying avoidably in the NHS every year. This must stop. Patients with a learning disability experience delays in diagnosis, delays in treatment, lack of basic care and poor communication by health professionals. This is simply unacceptable. The Government must take action to ensure that people with a learning disability get the right healthcare within the NHS and put an end to this scandal of avoidable deaths.”