A grandmother choked to death on a sandwich in hospital because staff had failed to note she was not wearing false teeth and therefore needed to serve her softer food or soups.
Lilian Hugill, 84, had been admitted to York District Hospital after becoming confused and was found to be suffering from a urine infection.
However, medical staff who admitted her to the Acute Medical Unit failed to note she was not wearing her bottom set of dentures, despite being prompted to ask the question in the hospital paperwork.
As a result she was wrongly given an egg sandwich with crusts just hours later, choking on it and suffering a heart attack and hypoxic brain injury, which led to bronchopneumonia.
She died a week later, a death her family say highlights how elderly patients are being let down by hospitals and treated as ‘just another number’.
Mrs Hugill’s daughter and son-in-law, Linda and Mike Garbutt, have successfully taken legal action against York Teaching Hospital NHS Foundation Trust, through medical negligence specialists Hudgell Solicitors.
The Trust admitted that had appropriate care been provided, Mrs Hugill would not have choked and her death would have been avoided.
‘She was let down at the time she needed good healthcare most’
Mr Garbutt, 63, from Thorganby, near York, said: “How can someone be admitted to hospital with a basic urine infection and this happen?
“Lilian was let down at a time of life when people most need good healthcare. She was let down by the poor standards of care and she was just another number. People don’t have that vocational spirit any more.
“You don’t expect to get a call with such devastating news from the hospital on the same day a relative has been admitted with a basic urine infection. It was just hours after she had been admitted to the Acute Medical Unit.
“We got a call from the hospital to say we should get there quickly and were taken into a side room. The nurse said Lilian had stopped breathing and had a heart attack, but that they had managed to restart her heart. They didn’t say what it was about, but the registrar then told us there had been a choking incident and that she had choked on a sandwich.
“I couldn’t believe they gave her that when she didn’t have a complete set of teeth. They kept her comfortable on morphine but she passed away a week later. She was only conscious very briefly during that time and she knew who we were but she couldn’t communicate. It was devastating.
“It is just a basic lack of observation. We don’t want anyone else to go through this and that’s why we’ve spoken out. Something has to be done to improve standards of care and to make sure lessons are learned.
ted string of failures in care which led to patient’s death
Mrs Hugill, a former print manager at The University of York, had been admitted to hospital with confusion in April 2014 and was diagnosed with a urine infection.
As part of the legal case, it was alleged a staff nurse failed to ask whether she wore dentures, as prompted on admission forms, or, if such a question was asked, failed to record the response in the patient documents.
The Trust was also accused of failing to put standard procedures in place at meal times on the acute medical unit to ensure suitable food was served and observations took place.
Solicitor Tasmin White said: “This is a really tragic and upsetting case and one where had the very basic standards of
care with regards to treating elderly and vulnerable patients been followed, this lady would not have died.
“Mrs Hugill needed dentures to eat and never ate without them, yet the hospital failed to establish that basic fact on admission.
Medical care can sometimes be complicated, but this was as simple as not noting a need to wear dentures and arranging a simple way for all staff to be aware of the need to serve soft food or soup, or to indicate she struggled to chew food and needed to be observed closely or supported. A simple sign on her bed could have done that.
“For such a basic error in care to cost a family their loved one is quite simply appalling.”
In addition to the error over her dentures, it was also alleged in the legal case that delays in calling crash teams caused Mrs Hugill’s airway to be blocked for an extended period of time, and that had she been treated within a few minutes she would not have suffered the brain injury and would not have died.
The Trust admitted a staff nurse had failed to ask and document whether Mrs Hugill wore dentures and admitted that, had such checks been made, staff distributing meals would have known.
It also admitted that had the issue around dentures been noted, she would have been put on a soft diet, and on the balance of probabilities would not then have choked. As a result her brain injury, bronchopneumonia and death would have been avoided.
The Trust also accepted that had Mrs Hugill been intubated sooner, the severity of her brain injury may have been reduced, but said its response to the arrest call had been in line with standard and acceptable procedures.
It stressed it has since taken steps to improve patient care by relocating the nursing station into patient bays and providing mealtime assistants.
Mrs Hugill’s family received a five-figure damages settlement following the admitted breaches of duty, and her family say they will always struggle to come to terms with what happened and how she died, especially given she had battled other illnesses including bladder cancer.
“It has affected our family massively,” added Mr Garbutt.
“She lived independently and her main interest was raising money for the church. Linda’s dad passed away 20 years ago, so Lilian threw herself into fundraising.”
Mr Garbutt said his involvement with Hudgell Solicitors was positive and communication was clear throughout the case.
“Hudgell Solicitors have been very thorough,” he said. “We weren’t bothered about claiming compensation. We just wanted the Trust to be held to account for getting it so wrong. It took a long time for them to do that and we are still coming to terms with what happened.”