A fit and healthy retired nurse in the United Kingdom died after staff at a hospital checked the wrong patient’s notes which had a “do not resuscitate” order in place. According to the Metro, 73-year-old Pat Dawson died in September last year at Royal Blackburn Hospital in Lancashire. She worked as a National Health Services (NHS) hospital nurse for 30 years. She was enjoying her retirement when she was rushed to the accident and emergency (A&E) department for the first time with suspected bowel obstruction.
On that night, the A&E department had been categorised as “overcapacity and overstretched” an hour before Ms Dawson visited with her son, Metro reported. She was taken to the Resus area as A&E was under overwhelming pressure. Hours later, she was pronounced dead, as per the outlet. An inquest heard on Tuesday how the retired nurse would have survived if medics hadn’t checked the wrong patient’s notes which had a “do not resuscitate” order in place.
“It is beyond belief the catastrophic way in which she was failed, not only by one individual but by doctors who have sworn the Hippocratic oath to do no harm and our mum paid the ultimate price,” Ms Dawson’s son John said in a statement.
The court on Tuesday was told that Ms Dawson was left waiting for a “significant period” of time after at least two nurses failed to return with a commode to allow the 73-year-old to go to the toilet. Her son ended up wheeling Ms Dawson to the toilet himself. He regularly asked his mother if she was ok but on asking a third time he received no response.
When the hospital staff entered the toilet, they found the 73-year-old slumped against the wall with dark fluid coming from her mouth. They noticed that she had no pulse following which they started CPR quickly which resulted in a return of spontaneous circulation.
Ms Dawson was then taken into a room but her heart stopped beating a second time. Nurses went to check the notes and returned to inform her son that she had a “Do Not Resuscitate” in place and she passed away less than 4 hours after she had arrived at the hospital.
As John sat with his mother after she had been pronounced dead a senior nurse informed him of the mistake. Not only had nurses checked the notes of an entirely different patient, but they had also failed to check the NHS number on Ms Dawson’s wristband, the court heard.
They had not even confirmed her age and gender on the notes. The patient whose notes were confused for Ms Dawson’s was a 90-year-old man, the court was told.
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“Unfortunately, tragically and catastrophically these were not Pat’s records; they belonged to an entirely different patient who was male and in his 90s; characteristics which Pat very clearly did not share,” Area Coroner Kate Bisset said, as per the outlet.
“It was quickly realised that a DNR was not in place however, tragically, it was too late,” she added.
Emergency consultant Dr Ahmad Alabood told the inquest it was an “honest mistake because (staff) were rushing”. He admitted that it is probable that Ms Dawson would have been resuscitated had medics attempted to do so.
The court ruled of neglect and concluded that Ms Dawson would not have died when she did if these mistakes had not been made. Royal Blackburn Hospital has also implemented several systemic changes since the 73-year-old’s death after an internal investigation flagged various concerns.
