A hospital trust has admitted mistakenly giving oral medication to a ‘nil-by mouth’ patient who died just three days after being admitted due to having problems swallowing.
The 78-year-old father-of-three was admitted to Hull Royal Infirmary on November 6, 2020. He had been rapidly losing weight and went in for an x-ray after the GP told the family he needed a feeding tube inserting into his stomach.
As the retired sheet metal worker was admitted during strict Covid restrictions, his family were not able to visit him.
Just a day after his admission, the hospital called his wife and informed her that her husband had mistakenly been given medication orally, and that an internal investigation had been launched.
The investigation confirmed he had been given a tablet of slow-release analgesia, orally, during the night shift of the November 7. Prescription records also revealed he had also been given the medication at 10pm on the November 6, and at 8am on November 7.
The oral medication caused the man to vomit and on November 7, he went on to develop aspiration pneumonia. Despite being placed on antibiotics, his condition deteriorated and he died on November 9.
The family were not informed of his deterioration at the time, as a nurse accidentally called the man’s own mobile phone instead of his wife’s.
By the time they were contacted and asked to attend hospital, he had already passed away.
Now, following a medical negligence claim through specialists Hudgell Solicitors, the Trust has admitted breaching its duty of care.
However, despite an independent Consultant Respiratory Physician; who was consulted as part of the legal case; being of the opinion that had the patient not been given oral medication he would not have aspirated into his lungs, and would not have died when he did, the Trust denied that its errors had caused his death.
They did, however, offer an out-of-court damages settlement which has now been accepted by the family.
‘It’s destroyed us all’
The man’s daughter said: “When he went into hospital they said he would be nil by mouth as he couldn’t even have sips of water.
“On the Saturday night, my mum rang his mobile and he was not answering and she tried calling the ward. She was told by a nurse that he’d been sick and my mum was really upset and said ‘what do you mean? He can’t be sick, he can’t swallow. Mum was very distressed.”
The family arrived at the hospital the following day to take some belongings but were not allowed to see him due to restrictions at the time.
The daughter said: “I rang him that night and he could hardly talk, I asked what was wrong and he said he was on a nebulizer and he couldn’t breath but he said ‘I’ll be alright’. Those was the last time I spoke to him.”
On the morning of November 9, the hospital left a message on the patient’s wife’s landline answering machine, and when she called back she was told to get to hospital as soon as she could.
His daughter said on arrival they were met by a nurse.
“The nurse said she was sorry, he had passed away early that morning. My mum said they didn’t ring her to say he was deteriorating, and my brother checked her phone and there were no missed calls,” she said.
“When we later got my dad’s belongings there were missed calls from the hospital on his mobile instead. They were ringing dad to tell him he was dying instead. We were in shock.
“They wheeled him into the room next door and we all went to him. I’ll never forget the look on his face. His eyes were open and he looked awful. I’ll never get that image out of my head.
“We weren’t expecting it, we thought he was going in hospital to solve the problem. He wasn’t a well man but not at the point of passing away. He was fine on the Saturday.
“I can’t get my head around why they’ve admitted doing something wrong but won’t take accountability for his death. It’s been three years now, but I don’t think I have really grieved until now because I have been wanting somebody held accountable.
“It has completely destroyed my mum. It’s completely destroyed us all.”
Legal case highlighted ‘serious and most basic mistakes’
Kirsty Yates, of Hudgell Solicitors’ medical negligence claims team, said: “This was a particularly sad case.
“When this man was admitted to hospital there was no evidence of an acute respiratory problem, and within a matter of days his family were having come to terms that he had lost his life.
“This awful situation was of course compounded by the fact serious, and the most basic mistakes were made in his treatment. These were mistakes which an independent expert, consulted as part of our case, felt had contributed to the man’s death.
“The Trust denied this at all times which only added to the family’s distress.
“They were minded to take the matter all the way to court, such was their determination to ensure full accountability and transparency. Ultimately though, given the Trust finally made a realistic settlement offer to resolve the matter, the decision was taken, with legal advice, to accept and bring the case to a conclusion.”
“This was a case where there was poor communication across the treating team, leading to wholly avoidable errors, which continued with the lack of information relayed to the family as the patient’s condition deteriorated, and after his death. It is a case from which many lessons need to be learned.”
‘Trusts should apologise and support families after mistakes’
The man’s daughter says she would like hospitals to change how they deal with grieving families as they never received a phone call or letter of explanation, or an apology following her dad’s death.
“Whenever anything like this happens, they should get closest relatives in and actually speak to them and say they are sorry and they will explain. We feel like we were kept at arms’ length to protect themselves. They all closed ranks and they didn’t offer any help or support,” she said.
“I would also have liked our phone calls to have been recorded as it felt like it was our word against theirs. When we looked at their report it didn’t say that he had been sick. I won’t ever come to terms with it.
“Kirsty Yates from Hudgells was fantastic. We are never going to get my dad back, but we wanted accountability and that is why we took legal action.”
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