A grandmother who went into hospital with a broken arm died after she was not seen by doctors for three days – because they DIDN’T KNOW she was there.
Patricia Fowler, 75, was left languishing on a cardiac ward and was not seen on three separate days because a secretary failed to tell consultants she was there.
An inquest heard that her name had been on a list sent to consultants, but because she shared the same first name as another patient she was overlooked.
It was not noticed that Mrs Fowler was actually a different patient with a different surname.
Devastatingly, by the time the mistake was realised, Mrs Fowler had developed pneumonia and sepsis – which led to her death.
Now her family are demanding Blackpool Victoria Hospital, Lancs., be held accountable after losing the family matriarch simply because she went into hospital in January.
Scott Fowler, the youngest of Mrs Fowler’s four children, described the devastation felt as a result of their mother’s death.
Mr Fowler said: “Going into hospital killed my mother. The grief we all feel has devastated us and the personal guilt I feel is immense.
“She died on Wednesday 15 and I went into the hospital on the Tuesday night to see her – she looked terrible.
“I went up to the desk to tell someone and they just told me that she was tired and she’d be feeling better after a night’s rest.
“You know as a family when someone you love isn’t well and I knew something wasn’t right.
“The fact I didn’t push it or demand they do something is guilt I’m struggling to cope with.”
Mrs Fowler, a retired widow and grandmother of five, went to A&E on January 4 after falling and was admitted to hospital.
She was discharged two days later with plans to attend a fracture clinic the following week, but was readmitted on January 9 after being referred back by her GP with hyponataemia – low sodium – and worsening back pain.
After being admitted to the Acute Medical Unit, she was transferred to Ward 39, a cardiac ward, shortly before 3am on January 10.
She was seen two days later in the fracture clinic, but not reviewed by a consultant until January 13, when she was seen following ‘an acute deterioration’, the hospital’s serious incident report (SUI) said.
Mrs Fowler, from Fleetwood, Lancs., was then transferred to the Intensive Care Unit (ITU) with severe sepsis and placed on a ventilator.
Mrs Fowler’s death prompted an internal investigation from the hospital and an inquest into her’s death.
In a statement to the coroner, Angela Russell, medical secretary in the Care of the Elderly department, said patients’ names were written on a white board in the bed managers’ office, before the patients were shared among the consultants.
At the end of November, the list started to be sent by email – possibly because the number of patients had increased – and the list contained names, but no hospital numbers, NHS numbers, or date of birth.
Ms Russell added: “In this particular case there had been a patient with the same forename, which appeared in exactly the same place on the emailed list.
“When going through the list, it was not obvious that the patient’s surname had changed.
“I did not notice this and neither did any of the Care of the Elderly consultants.”
Anaesthetist Dr Matthew Bowker told a subsquent investigation he expressed concerns after Mrs Fowler wasn’t ‘reviewed by a member of her medical team’ from the time she was moved onto the cardiac ward until three days later.
Dr Anju Mirakhur also described the confusion as to who was responsible for looking after her.
He said Mrs Fowler was assigned to the Care of the Elderly team but was not seen on January 10, 11, or 12, before several calls were made to doctors on the 13th, which meant she was seen at 2.50pm, 8pm, and 10pm.
Sadly she died two days later on January 15, with a post mortem examination ruling the cause of death as sepsis and pneumonia, with her broken arm a contributing factor.
Mr Fowler, who lost his dad, Brian Fowler, in 2006, said: “Quite simply, my mum died because she went into that hospital.
“We all know that at some point we will lose our parents, but we expected my mum – who was perfectly well – to be here for years and years.
“You don’t die from a broken arm. You die from pneumonia and sepsis and she got those because she was left on that ward without doctors’ reviews.
”If she had been seen, or a nurse had noticed she hadn’t been seen, she would still be here now.”
One medic, Matthew Bowker, told the investigation there was ‘obviously no proper handover of care between medical shifts’, and said: “‘It could be argued that had a proper timely review taken place, the severity of her deterioration could have been prevented and she may have avoided admission to intensive care.”
The hospital has said lessons will be learned from the fatal error and its chief executive, Wendy Swift has written to Mrs Fowler’s family to apologise for the incident.
In a statement, the trust said: “Blackpool Teaching Hospitals NHS Foundation Trust has admitted liability in this matter and has passed on its sincere condolences and apologies to Mrs Fowler’s family.
“A full investigation was carried out into the circumstances of Mrs Fowler’s hospital journey and a number of changes have been implemented as a result of the findings of that investigation.”
However, Mr Fowler, who has two elder sisters, Steph, 56, and Deborah, 50 and an elder brother, Gary, 47, doesn’t believe that is enough.
The dad-of-two said: “We feel as though there is no accountability. They’ve admitted liability but that’s not enough.
“Something needs to change and we need to see more than just an apology.”