A 75-year-old woman died in a South Yorkshire hospital on Mother’s Day following ‘gross’ failures and neglect, a coroner has said.
Eileen Reynolds died at Barnsley Hospital on March 30 last year, one week after first being admitted suffering from gout and renal failure.
An eight-day inquest into the death of Mrs Reynolds, from Longfields Crescent, Hoyland, recorded that neglect had been a contributing factor to her death after she developed high levels of potassium, which were ‘not recognised or treated appropriately’.
In a joint statement following the hearing, her three children Julie, Alan and Susan said there had been ‘unforgiveable mistakes’ in their mother’s care.
The inquest heard that Mrs Reynolds was prescribed medication in hospital that caused her to suffer diarrhoea and potassium levels in her blood consequently dropped.
She was given potassium but became breathless and a blood test revealed abnormally high potassium results, but this was not acted upon.
After being left unobserved overnight, Mrs Reynolds suffered a cardiac arrest on the morning of March 30 as a result of these high potassium levels.
Assistant coroner Louise Slater said ‘individual errors’ were admitted by both junior doctors and nursing staff, with concerns raised about ‘understaffing and subsequent workload pressures’ from those who gave evidence.
She said there had been a shortage of junior doctors and had more been hired it would have ‘reduced the likelihood of these errors being made’.
But she said there was no evidence to suggest the number of junior doctors on the ward had fallen below the minimum requirement or that additional doctors would have prevented the individual errors from occurring.
Matthew Brown, a specialist clinical negligence lawyer with Raleys Solicitors, is representing Mrs Reynolds’ family.
Following the inquest he said: “This whole inquiry has revealed shocking facts about staff levels, the stressful conditions in which they were expected to work and the unsafe environment for patients on Barnsley Hospital’s Ward 27.
“This was made all the more horrifying when evidence presented throughout this hearing revealed that the Hospital and Trust management had been made well aware of the situation and had failed to take prompt, remedial action.”
A statement from Mrs Reynolds’ children said: “On March 29 last year, we recognised that our mum was unwell as she appeared short of breath whilst speaking to us.
“We feel immensely disappointed and frustrated at the total lack of concern and active management shown over our mother’s treatment on that day, and appalled at the night shift staff who failed, both in their ‘duty of care’ and to identify our mother’s deteriorating condition.
“At 8.10am on Mother’s Day, our mother had a cardiac arrest and died due to a high potassium level.
“They failed to inform us that the blood test the previous day had shown an elevated potassium level which nothing had been done about.
“If this had been corrected it would have saved her life.
“The hospital promotes their policies of being ‘open and honest’, good patient safety and quality of care, however we feel that these aspects were not reflected in the care we saw delivered.
“We feel distressed, angry and disappointed in the abysmal care and lack of concern shown towards our mother’s health and the failure to listen to our concerns regarding our mother’s deteriorating condition.
“During the inquest it was revealed that the managers of the hospital were aware of both medical and nursing shortages on the ward for a prolonged length of time and evidence demonstrated that this had clearly led to sub-optimal care for patients on that ward.
“We learned of how the night nurses had to ‘choose which patients to care for’ due to poor staffing levels and inappropriate skill-mix, and also that the Hospital was aware of poor staffing levels leaving doctors working extremely long hours under stressful conditions.
“As a family we feel that these poor levels of service provision not only contributed to the ultimate death of our mother, but also led to sub-optimal standards of medical and nursing care to other patients on that ward.
“We feel extremely shocked and disgusted that poor conditions like this were allowed to continue in a hospital setting with the full knowledge of the hospital managers, and unforgivable that these unsafe conditions and poor standards contributed to the numerous mistakes which led to the death of our mother.
“There are no more words to mirror the depths of emotion, pain, hurt and sadness we feel at the loss of our mother at the hands of Barnsley Hospital.”
Dr Richard Jenkins, medical director for Barnsley Hospital, said: “On behalf of the trust, I would like to apologise to the family of Mrs Reynolds for the deficiencies in the care she received.
“The trust had undertaken an investigation into Mrs Reynolds care prior to the inquest but we will carefully study the coroner’s findings to ensure that all necessary steps have been taken to prevent a similar situation from arising in future. Patient safety is paramount at the trust and we will continue to work to ensure our services are as safe as possible.”