Preventable ED death: trust failed patient with complex needs
Posted 19 December 2024 - 13:36
Coroner tells NHS hospital trust to take action over care of patients who have long waits in its emergency department, especially those with complex needs
A hospital has been told to urgently address the care of patients with complex conditions after a woman with spina bifida died having waited 39 hours in the emergency department.
Marina Young, 46, was taken to Royal Preston Hospital on 20 June 2022 following an asthma attack. After initial medical assessment and treatment, she waited for a bed. In that time, her nursing needs were neither assessed nor met in the ED, according to a senior coroner in a report to Lancashire Teaching Hospitals NHS Trust.
Emergency nurses failed to assess woman’s complex care needs or seek specialist input
In his report on prevention of future deaths, James Adeley said Ms Young had needed to self-catheterise every three to four hours, and when unwell, needed support with this. She also wore continence pads. However, none of the six nurses involved in her care in the ED assessed her toileting needs, offered her a fresh catheter or changed her pad.
The report added they did not take Ms Young’s sensory deficits into account, relying instead on her own assessment for pressure area care. As a result, and despite being overweight and incontinent, Ms Young remained in a chair for almost the full 39 hours.
The nurses did not escalate problems to senior nursing staff and did not request specialist support. When Ms Young died, she was still wearing the shoes she wore on arrival – she could not take off without assistance, Dr Adeley noted. He said the ED lacked nurses with knowledge of when basic assessment, such as peak flow, should be carried out.
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Preventable ED death attributed to failures in nursing observations, treatment and medical management
The coroner said despite Ms Young’s having an 80% chance of surviving her asthma attack, she died due to:
- Substantial failures of medical management
- Inadequate treatment
- Insufficient direction of nursing staff for observations
- Lack of referral to either respiratory or intensive therapy unit specialist teams
His report acknowledged the hospital was full at the time and its ED had a ‘bed block’ that prevented patients from being transferred out of the ED, which senior nursing staff would have known.
The coroner concluded Ms Young’s death as a result of asthma had been preventable and was caused by ‘neglect characterised by a gross failure to provide appropriate assessment and medical care’.
Dr Adeley told the trust that the care needs of people who remain in the ED beyond ‘expected’ waiting times – especially those with complex needs – should be assessed.
Preventing future ED deaths: trust aims to improve senior nurse oversight
A Lancashire Teaching Hospitals NHS Trust spokesperson said:
‘The trust would like to offer its sincere condolences to the family and friends of Marina Young and apologise for the failings identified in our own investigation and the coroner’s report.
‘We have taken the death of Marina extremely seriously and continue to take action to ensure the issues raised thoroughly addressed.
‘The actions focus on strengthening education relating to the management of asthma and the importance of peak flow and early respiratory in-reach for this type of presentation, as well as improving processes to increase senior nurse and doctor oversight of ED patients who have increased vulnerabilities experiencing longer lengths of stay.’
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