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Hospitals must improve levels of screening and response to stop sepsis causing thousands of preventable deaths

Doctors Hospital Corridor Nurse Pushing Gurney Stretcher Bed


Sepsis is now a bigger killer than any single form of cancer in the UK.

It causes 44,000 deaths each year, mainly because those suffering from the disease often mistake its symptoms for more common illnesses.

That is perhaps understandable in those not medically trained, but it is shocking to learn how many hospital trusts are failing to meet treatment guidelines – leading to patients not being screened for the disease, and not being given treatment quickly enough when it is diagnosed.

Sepsis starts with an infection, sometimes from something as minor as a contaminated cut or insect bite.

It causes the body’s immune system to go into overdrive, setting off a series of reactions including widespread inflammation, swelling and blood clotting.

This can reduce blood supply to vital organs, starving them of oxygen, and if not treated quickly, sepsis can lead to multiple organ failure and death.

It is a huge threat to life is now recognised by all involved in any form of health care, yet figures from 104 hospital trusts, seen by investigative BBC programme Panorama, has revealed concerning trends.

At Liverpool Heart and Chest Foundation NHS Trust, less than one in 10 patients who required screening actually received it during the 12 months to March 2017.

And even when hospitals identified the need for antibiotics, many failed to act quickly enough.

One in four failed to give antibiotics to half of patients recognised to have sepsis within the recommended time frame of an hour. At Bradford Teaching Hospitals NHS Foundation Trust, only a quarter of patients who were identified as suffering from sepsis were given antibiotics within the recommended time.

Every hour in delay of treatment raises the risk of sepsis death

Although sepsis can affect people of any age, is most common in the elderly and the very young.

It is a killer condition which it seems is yet to be fully understood not only by general members of the public, but by hospitals up and down the country.

Every 3.5 seconds, someone dies from Sepsis. It is the biggest direct cause of deaths in pregnancy in the UK, and studies now show it affects 260,000 people a year – 100,000 more cases than have been previously estimated.

Sadly, we have handled a number of cases at Hudgell Solicitors where the treatment of sepsis has been too slow.

When investigating the circumstances around sepsis deaths, we instruct independent medical experts to assess the treatment provided, and in each case experts have highlighted how every hour of delay in treating patients with antibiotics raises the risk of death.

The Panorama figures show that one in five eligible patients are not currently being screened for signs of sepsis, and Health Secretary Jeremy Hunt admits that the NHS now has “more to do” to stop “preventable” sepsis deaths occurring.

It is clear that despite the growing threat to lives, there are still many lessons to be learned about the need to identify symptoms early and take immediate action.

Breathlessness, confusion, extreme chills and shivering, muscle pain, fast breathing and heartbeats, feeling dizzy and faint and feverish are all possible early signs of sepsis

Loss of consciousness, mottled or discoloured skin, slurred speech and vomiting are also clear signs of danger.

Saying ‘there’s a long way to go’ seems a massive understatement from Mr Hunt.

With an estimated 14,000 preventable deaths every year in the UK, hospital trusts must make improving their care in this area a priority and quickly find much better ways of identifying and treating sepsis earlier.

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15/09/2017 No Comments

Health Trust admits neglect of district nurses left elderly patient with shocking bed sore causing agonising pain for last 12 months of her life

Elderly woman in bed | Hospital negligence leaves woman suffering from serious bed sores


A great-grandmother suffered agonising pain for the final year of her life as district nurses failed to properly treat a bed sore which allowed it to develop into a ‘weeping black hole’ in her lower back.

The 84-year-old woman, who had Alzheimer’s Disease, was bedbound due to frail health and lived with her family at their home in Lambeth, South London.

Having developed a small bed sore, her family called their GP who arranged for district nurses to visit three times a week.

However, during her care – which nurses reduced to just one day a week — she developed a second sore where dressings had been removed by nursing teams from the initial wound, which they then failed to treat appropriately.

Despite raising concerns over her worsening conditions, the woman’s family say they were dismissed by the district nurses.

A subsequent examination, however, revealed the second sore had become so bad that they were considered to be Grade three or four — the most severe where skin is severely damaged and underlying muscles or bone are in danger of being damaged.

Around 90% of the woman’s skin in the area of the sores had become necrotic and had therefore died.

It led to the district nurses, employed by London’s Guys’ and St Thomas’ NHS Foundation Trust, being instructed to visit daily again and the elderly woman being admitted to hospital due to an infection.

Following discharge from hospital, the woman required ongoing care from her family, as well as another set of district nurses, until she died some 10 months later, on April 4, 2014, aged 85.

Black sore had to be ‘cut away’ in hospital

The woman’s daughter, who has asked not to be named, said she could not believe how the problem had been allowed to escalate from a small initial sore when they first sought medical support.

“Mum developed a really small sore, which looked like a graze and I was told that I should call the doctor at the first sign of anything like that, so I did,” she said.

“Mum’s skin was paper thin. When the initial mark had gone, the dressings the nurses were using were too sticky and caused the second sore. I kept asking what it was and they said it was nothing. But then it went black and ended as a weeping black hole.

“When mum was in hospital, they had to cut the black area away. I put in a complaint to social services and had meetings with them, as well as the Patient Advice and Liaison Service (PALS) and safeguarding. I went to meeting after meeting.

“Mum had a specialist chair at home, but by the time she came out of hospital the sore was so bad that even the nurse was frightened to get her out of bed. She was completely bedbound and in pain, but with her having Alzheimer’s, she couldn’t communicate how bad it was.

“She previously had throat cancer and had a tracheotomy, so she’d already been through so much, so to watch her deteriorate in front of our eyes was heartbreaking.

“The treatment my mum received was disgraceful. They neglected her. We did everything for mum and that was our choice as a family. But we didn’t want her to suffer on top. You should be able to believe and trust what a nurse says.”

£25,000 damages agreed after medical negligence legal claim against Trust

Following legal action, through medical negligence specialists Hudgell Solicitors, Guys’ and St Thomas’ NHS Foundation Trust admitted the nursing care fell below the standard to be reasonably expected and agreed to pay the woman’s family £25,000 in damages.

The Trust also admitted the patient had not been assessed properly for the sores, nor was she placed on an appropriate mattress despite being at a high risk of developing sores having had several additional health problems.

It also admitted that, as a result of the inadequate care and the sores deteriorating into a Grade three or borderline Grade four, she developed an infection for which she was admitted to hospital and suffered prolonged pain and suffering for 12 months.

Kirsty Yates, of Hudgell Solicitors, represented the family throughout the case and said it was a clear case of negligent care.

She said: “The last 12 months of this lady’s life were spent in a lot of pain and discomfort, which was terrible for her and her loving family who cared for her and loved her.

“Her family could only do so much and they put their faith in the Trust and the nurses, but they failed to provide the care expected.

“As she was elderly and bedbound, she was at high risk of pressure sores anyway, so it was completely inexcusable not to conduct pressure ulcer risk assessments and make appropriate plans for treatment.

“Research suggests 95 per cent of pressure sores can be avoided by providing appropriate bedding, and making sure patients move and, if necessary, are turned regularly. This shows situations like this should be avoided.

“The fact that the second sore then developed, and was allowed to deteriorate to the extent that it did, was shocking.”

The woman’s daughter added: “When mum died her death was put down to pneumonia, but I also believe the sore didn’t help because it never got any better, it only got worse.

“Mum was a brilliant person and we were so close. She brought seven of us up on her own and worked hard all her life. She didn’t owe anyone a bean and she was a warden for people living in sheltered housing, so she really cared for other people.

“She was a very respectable woman and I wanted her to have dignity and respect in her later years. But what happened to her was completely degrading.

“When I turned to Hudgell Solicitors, it was the same month my mum passed away and I wanted to take it further to get my point across about how she was treated. I wanted them to be held to account. Kirsty did that superbly and was always there when needed.

“I don’t want anyone else to have to go through this. My mum went through this with a big family. What about the people who don’t have anybody? There are lots of people who don’t have any family or support.”

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29/08/2017 No Comments

Hudgell Solicitors welcomes national safety review of hand sanitisers on hospital wards after death of elderly patient who drank full bottle

John Haughey | Elderly Patient Drinks Hand Sanitiser in UK hospital


Hudgell Solicitors has welcomed a national review over the safety of hand sanitisers on hospital wards following the death of an elderly patient at Hull Royal Infirmary who became confused and drank a full bottle.

John Haughey, 76, consumed the equivalent of a litre gin when drinking the 75% alcohol gel from the bottom of his hospital bed.

Following a legal case led by Hudgell Solicitors, Hull and East Yorkshire Hospitals NHS Trust recently admitted breach of its duty of care and agreed an undisclosed damages settlement with his family, having not disputed being liable for Mr Haughey’s death.

The incident sparked a national safety alert as Hull Coroner Prof Paul Marks wrote to NHS England highlighting his concerns that more deaths could be caused if changes are not made on hospital wards and lessons learned.

As a result, redesigns of bottles to limit the amount they dispense, and new protocols for medical professionals to follow should similar incidents happen, are now being considered.

Legal case highlighted failure to properly monitor patient after incident

The legal investigation into the matter highlighted how staff at Hull Royal Infirmary failed to act appropriately in the wake of the incident, errors which contributed to Mr Haughey failing to recover and dying a few days later.

At an inquest, evidence was heard from a pathologist who said Mr Haughey’s death of bronchopneumonia was ‘highly significant’ and that there had been a direct link between consumption of such a high percentage of alcohol and pneumonia.

The coroner concluded that inadequate observations had been made of Mr Haughey as he fell into a coma, as medical staff failed to record observations under the Glasgow Coma Scale, which would have given them a clearer indication of his state of consciousness.

These errors contributed to his airways being left ‘unprotected and vulnerable’ for seven hours, the coroner concluded.

Various medical professionals gave evidence to say that earlier steps should have been taken to support Mr Haughey’s breathing.

Solicitor Michelle Tebbutt says lessons must be learned around safety and medical response

Solicitor Michelle Tebbutt, of Hudgell Solicitors, represented Mr Haughey’s family and says that no matter what comes of the debate around the use and storage of gels on patient wards, there was a clear failing of staff at Hull Royal Infirmary to act appropriately.

She said: “This is a truly tragic case which has highlighted many areas of concern with regards to safety on hospital wards of confused patients.

“There is obviously a matter of significant national interest with regards to the appropriate use of sanitiser gels and their availability to vulnerable patients, and it would of course be very disappointing should we now see any more avoidable deaths in similar circumstances given the comments made by the coroner.

“Sadly, this case also highlights shockingly poor care provided to a vulnerable patient at Hull Royal Infirmary.

“Mr Haughey had consumed the equivalent to a litre of gin, and it was therefore only safe to assume the worst. Independent medical experts told the inquest into his death that it should have been assumed that he could become unconscious within the next hour or two, at which time there would have been a risk of aspiration.

“His treatment should therefore have been supportive and active in terms of ventilation to protect his airway. The observations made were simply not satisfactory and left him in great danger.

“He was unresponsive for close to seven hours before becoming completely unconscious, by which time his airway was in jeopardy.  There was a risk of aspiration at all times, it was inevitable that he would become unconscious and not to take immediate action was a serious failing in care.”

Family upset by hospital’s errors and lack of information and compassion

Mr Haughey’s daughter, Diane Atkin, criticised the Trust for not only its failings in looking after her father, but also its treatment of her family in the wake of his death.

She says they were ‘economical and not forthcoming with the truth’ until the inquest was held and legal action launched through Hudgell Solicitors.

“It has been a disgrace from start to finish we were kept  in the dark with very little information by the Trust over what had happened to my father, how it had ever been allowed to happen and the failings in treatment after he had swallowed the gel,” she said.

“First of all there were obvious questions over the hand gel, something we know has now become a national issue thanks to the support of the coroner. The top was so easy to unscrew and so easily accessible that it was an accident waiting to happen.

“What hurt us more though was the fact that we were shown no respect as a family and my father suffered from such poor care. He went into hospital for his safety, rapidly went downhill and never came out. When the incident happened we didn’t learn about it until four hours later. They then just left him in a room and didn’t monitor or support him as they should.

“Even when he was dying and we went in to say our goodbyes a nurse told us we couldn’t all be by his bedside at once. There was very little compassion.

“We asked questions afterwards but never got answers. It was only when we had the inquest that the NHS were forced to answer questions by the coroner and we started to find out what went wrong. Before that we just hit a brick wall and I think it is disgraceful for families who lose loved ones due to the negligence of hospitals to be treated in this way.”

Ms Atkin says her father, who had lived independently before being admitted to hospital, had become unwell with what was believed to have been a chest infection, and despite often being forgetful or confused, had not been diagnosed with dementia.

She says he told her he ‘felt safe’ when leaving him at hospital, but when she visited him the next day he was ‘completely different and totally confused’.

Just days after being admitted, she said he ‘didn’t know what he was doing’ and was not eating his meals.

It was on his fifth day in hospital that Mr Haughey drank a 535ml bottle of Purell hand sanitizer from the bottom of his hospital bed.  This took his blood alcohol levels to between 35-40 units, but despite this, no immediate action was taken by medical teams to assist his breathing.

A serious incident report compiled by the Trust detailed how Mr Haughey had to be restrained by medical and security staff after drinking the gel so that he could be injected with a sedative, as he became ‘agitated and violent’.

By the time Ms Atkin was called and attended at hospital some hours later, she says her father was ‘seriously ill’, unconscious, and ‘covered in bruises’.

“I couldn’t believe how he looked when I got to hospital,” she said.

“He was unconscious and had severe bruising. He had bruising on his chest like somebody had sat on him and bruising to his wrists. We were simply told at the time that he had been restrained to calm him, but I was not happy to see him bruised the way he was.

“Then, I heard evidence at the inquest from a social worker that one of the nurses had been aggressive towards my father two days later when he was in intensive care and had regained consciousness.

“It was alleged the nurse said that we’d told her my father ‘was not a nice man’, so that he would hear it, and that she pulled part of his mask that was there to help his breathing away from him. It was alleged she also grabbed at his arm and she was also overheard saying ‘I’ve had to come out of the room before I hit him’ as she came out of the intensive care room.

“It was totally heart-breaking to hear and to think my father was put through all of this.  In the end we did get an apology from the Trust, but it wasn’t sincere.  If they had been sincerely sorry they would have been open and honest from the start about everything that happened.

“They throw apologies around like confetti when facing legal actions, but that is no comfort to families who lose loved ones. We were made to feel in the way and a nuisance as my dad was dying.

“It seems to me that there is a vast difference between the standards of care and that the elderly are not properly cared for. I saw elderly people wandering around and being left for hours without any one-to-one interaction. They leave the food and water with them and that’s it.

“More recently, my son needed emergency treatment for appendicitis at Hull Royal Infirmary and they were absolutely wonderful. They could not have done more and it was like being at a private hospital. Questions have to be asked about the standards of elderly care and the differences between wards. It is not acceptable.”

Safety of hand gels in hospitals has become a national issue

Since Mr Haughey’s death, coroner Prof Paul Marks has contacted NHS England in a bid to prevent future deaths. He also wrote to The Royal Society for the Prevention of Accidents; The Health and Safety Executive (HSE), Nuffield Health; BMI Healthcare and the Spire Healthcare Group.

As a result, NHS England’s medical director, Sir Bruce Keogh, has responded to highlight how latest NHS guidance stresses the need for detailed risk assessments of where gels are placed in relation to vulnerable patients.

He added that NHS Improvement is also exploring designs which could limit the amount of alcohol gel released from dispensers, and proposing to gather information to help develop standardised care procedures for situations where patients accidentally swallow such gels.

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14/08/2017 No Comments

Compensation for mum who missed bonding time with new son following hospital’s ‘hazardous’ medication error

Newborn baby feet on mother


A mother says she missed ‘irreplaceable’ bonding time with her new-born son during the first few months of his life as mistakes by doctors left her taking a mix of medication causing anxiety and hallucinations.

Emma Houghton, 41, from Portsmouth, had enjoyed a smooth pregnancy and a problem-free caesarean birth as she and her husband Benjamin welcomed their son Noel into the world.

However, after returning home, Mrs Houghton began suffering severe anxiety, insomnia, memory loss, tremors, sweating, vomiting and hallucinations, with the symptoms lasting around three months.

Solicitors acting on her behalf in a legal claim against Portsmouth Hospitals NHS Trust, which runs the Queen Alexandra Hospital where Mrs Houghton had Noel and was treated in the weeks afterwards, claimed medication she had been prescribed left her ‘filled with anxiety and ill health’ and unable to bond properly with her son.

The problems began when Mrs Houghton suffered “excruciating” pain in her chest days after returning home.

Doctors believed it to be musculoskeletal related to the birth and prescribed her with Tramadol in a bid to ease her suffering – a drug which should not have been suggested as she was already taking Imipramine to tackle anxiety and panic attacks.

The combination of the two drugs is noted as being “potentially hazardous” in the British National Formulary pharmaceutical reference book.

Medication made new mum feel ‘anxious and spaced out’

Having started taking the medication, Mrs Houghton says she immediately began to feel anxious and ‘spaced out’, and says it was only after seeking advice from a psychiatrist, and having made further trips to the hospital, that she realised the error had been made.

“When I started taking the Tramadol, my anxiety was so extreme and I couldn’t do anything with Noel,” she said.

“Within a couple of hours, I thought I could see a cat in the garden and I was completely tripping out and hallucinating. I was spaced out. Feeling like that would normally scare me, but I was so out of it, I thought it was okay.

“After 10 days of feeling like this on the Tramadol, I couldn’t take any more. I knew I wasn’t bonding with my baby so I stopped taking it, cold turkey. Within 24 hours, my anxiety was through the roof. I felt like I did before I started taking my medication and it was overwhelming, shear panic, and I couldn’t eat or sleep.

“I went to see my psychiatrist after speaking to him on the phone twice and not once did he relate my symptoms to postnatal depression or anxiety. He said it was all down to the Tramadol. He looked it up and it was a very hazardous combination with Imipramine.

“I was gutted as it had been a medical error that had made such an impact on my life and my first weeks with Noel.

“The pain I experienced was extreme. I don’t want to be on anxiety medication and want to be more in control of it as it comes on for no reason at all. It’s a chemical imbalance and all I can do is live a healthy lifestyle.”

Damages awarded to reflect impact on mum in early months of son’s life

Mrs Houghton has now been awarded £3,000 damages following her legal claim through medical negligence specialists Hudgell Solicitors.

She says she missed out on crucial time with Noel in the first few weeks of his life, as she was unable to breastfeed and do any more than simply hold him.

“On the first full day I breastfed him once, we were worried he wasn’t going to come round. It was the scariest thing ever, so I stopped and put him on formula,” she said.

“I could hold him but there wasn’t any bonding and I couldn’t breastfeed. I was really disappointed because I really enjoyed breastfeeding and looking after him and those early months of bonding are irreplaceable.

“For the first few weeks, I was very angry, upset and emotional. It was horrific. It wasn’t until I went back to A&E about my pain a few weeks later that I realised how big an error had been made. I told one of the doctors what I’d been prescribed and he couldn’t believe it.

“It was heart-breaking to know it was someone else’s fault when I had taken every precaution possible and that a medical professionals didn’t take the time to check.”

Legal claim highlighted medication error and failure to recognise likely adverse reaction

The legal claim against the Trust alleged it had unreasonably prescribed Tramadol to Mrs Houghton while she was taking Imipramine, failed to note the adverse reaction it could cause and instead had incorrectly advised her it would not be a problem.

It was also alleged the Trust failed to obtain Mrs Houghton’s informed consent for the prescription, as she would have refused it if she’d known how it could affect her, failed to arrange a follow-up appointment and failed to keep a reasonable record of the consultation.

As a result, it was alleged she suffered anxiety for three months, as well as other symptoms including insomnia, memory loss, tremors, sweating, vomiting and increased hallucinations, inability to bond with her son, and a delay in reducing her Imipramine prescription.

The Trust admitted breach of duty in prescribing and administering Tramadol while she was taking Imipramine, but denied the Tramadol caused a relapse of her illness, offering the £3,000 settlement out of court.

Patient urges other new mums to take care with all medication

Mrs Houghton now wants other patients to learn from her case and be vigilant when being prescribed any medication.

“I don’t want anyone else to go through this. It might not occur again but I wanted to hold someone liable for the time I lost bonding with my son. It should have been a happy time. My son is beautiful and funny, and we are very thankful for everything we have,” she said.

“It was well documented in my notes that I was taking Imipramine. I saw my psychiatrist before and during my pregnancy to check if there was anything I needed to be aware of regarding my medication and I followed everything I was supposed to do.

“I’m so cautious with everything, even cough medicines, and I would rather break every bone in my body than have anxiety again, but you trust a hospital where you give birth to be right.”

Mrs Houghton, a divisional sales manager for an international beauty and fashion company, said the pain she had experienced following the birth of Noel, now 22 months, was eventually attributed to a car accident she had been involved in two weeks before he was born.

She said doctors believed the muscles affected had been protected by Noel and the pain only surfaced once he had been born.

Legal case resulted in damages and apology from Portsmouth Hospitals NHS Trust

Nicola Downey, of Hudgell Solicitors, coordinated Mrs Houghton’s case and says she hopes the admission of breach of duty by the Trust goes some way to acknowledging the serious errors made.

She said: “Having a baby, especially your first, is a huge event in your life and can often bring about a range of different emotions and feelings.

“Mrs Houghton was acutely aware of how her anxiety affected her and rightly asked questions about how medication could affect her while she was pregnant and still taking Imipramine.

“Unfortunately, the prescription of Tramadol had such an adverse effect, it affected her ability to properly bond with her son in those vital early stages.

“What should have been a time of joy and happiness was instead filled with anxiety and ill health as a result of this medication error.

“I’m pleased Mrs Houghton now has the admissions she wanted and can move forward knowing we have reached this outcome.”

In legal correspondence, the Trust said it empathised with Mrs Houghton at “what must have been a very distressful time” for her, and said it was “very sorry for the error”.

Mrs Houghton, who says she would like to have another baby, praised Hudgell Solicitors for their support in challenging her care and said she was grateful for Nicola’s care and compassion throughout the case.

She said: “Nicola has been perfect throughout everything and very understanding.

“She was one of the most sympathetic people in terms of listening and understanding, and I would recommend her to anybody should they suffer in a similar way.

“Now, I want to move on but I still remain angry that someone else impacted on my future with my son because of their negligence.”

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07/08/2017 No Comments

Poor Care Leading to ‘Shocking’ Death Rate in NHS Hospitals

Hospital staff with oxygen mask Poor care leading to shocking death rate in NHS hospitals-min


Sick patients in NHS hospitals are dying ‘unnecessarily’ according to a new inquiry, with poor care and lack of equipment attributing to a worsening death rate.

Patients who need emergency help for breathing problems are most at risk, with one-third of inpatients dying due to ‘major flaws’ in the treatment they receive. The death rate for people with breathing difficulties is already high by international standards, and is getting worse.

The findings come as part of the National Confidential Enquiry into Patient Outcome and Death study, which analyses patient outcomes across all NHS services. Investigators charged with publishing the NCEPOD report described the findings as ‘shocking’, blaming the sharp rise in deaths on mismanagement, delayed diagnosis and inadequate equipment across the health service.

Between February and March this year NCEPOD investigators examined 353 patients with serious breathing difficulties, and found that the vast majority received substandard treatment. Many of the patients assessed suffered from pneumonia, pulmonary disease or similar conditions which meant they couldn’t breathe unaided. In some cases, hospital staff failed to administer non-invasive intervention (NIV) through an oxygen mask, resulting in unnecessary death and suffering.

Shockingly, patients received poor care and inadequate monitoring of symptoms in four out of five cases. Treatment was often delayed due to a lack of equipment, and the failure of medical staff to recognise when NIV was needed. Doctors involved in carrying out the NCEPOD assessment were appalled by the findings, stating that their hard-hitting conclusions were justified.

In an emergency, NIV treatment administered in hospital is supposed to reduce the risk of death from 20% to 10%. However, the NCEPOD study revealed that the average death rate in the UK is closer to 35% — significantly higher than expected. By contrast, the death rate in Spain is 18% and 10% in France. According to historic NCEPOD data, the UK death rate has been rising since 2011, when it first reached a high of 30%.

Are Spending Cuts to Blame for High Death Rate in NHS Hospitals?

The NHS has faced crippling spending cuts in recent years, with resources severely impacted across all services. The NCEPOD report found that two out of five hospitals have been unable to cope with inpatients that need NIV help with breathing problems due to a lack of equipment, including basic ventilators which cost anywhere from £1,000 to £2,000.

The report also revealed that a shortage of nursing staff is partly to blame for rising death rates. Staff shortages were reported in one-half of all hospitals assessed by the NCEPOD, meaning that a vast majority are failing to offer the proposed staffing ratio of one nurse to two NIV patients — putting lives at risk.

While it’s clear the NHS spending crisis is partly to blame for the rising death rate, it’s troubling that many deaths could have been prevented by a timely and accurate diagnosis, and the administering of appropriate treatment and care.

Mismanagement, delayed diagnosis and poor treatment of NIV patients are inexcusable, and more must be done to improve services in NHS hospitals. It’s scandalous that the current UK death rate for NIV inpatients is nearly double that of other European nations — highlighting the gross failings of our health service.

Misdiagnosis or delayed diagnosis of serious health conditions can have a life-changing impact. If you or someone you know has been affected by medical negligence, visit our hospital complaints page to find out we could help.

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18/07/2017 No Comments

Family of woman who died after surgeon implanted heart valve upside down continue to ‘fight for justice’

Heynes Family | Hudgells Solicitors


The family of a woman who died after a surgeon mistakenly implanted a heart valve the wrong way up say the inquest into her death failed to substantially hold him to account for causing her death and has left them asking more questions.

Sheila Mary Hynes, 71, died in intensive care a week after undergoing what her family were assured was routine surgery.

Surgeon Asif Shah, of the renowned Freeman Hospital in Newcastle, has carried out more than 350 open heart operations since starting at the hospital in January 2015 and prior to this week’s inquest.

However, the operation on Mrs Hynes was the first time he had done this particular procedure as the lead consultant.

Surgeon was ‘unaware’ heart valve could be implanted upside down

Mr Shah told an inquest – for which the scope had been extended to allow the coroner to investigate under the Human Rights Act – that the procedure had been ‘going OK’ until the very last moment, when he was tying down the valve and the stitch cord snapped.

He said this meant he needed to remove the valve and hand it to a scrub nurse ready for him to re-fit it. He told coroner Karen DNikki TV ilks that it was at this stage that the valve must have been placed on its mounting the wrong way round – something he was unaware could happen.

As a result he said he inserted the valve the wrong way round and stitched up Mrs Hynes, who never woke from the operation, as the mistake caused irreversible damage to the left ventricle and her heart.

She died in intensive care a week later, after a second operation to try and get her heart working again failed.

Hospital Trust admits breach of duty as part of ongoing negligence claim

Newcastle Upon Tyne Hospitals NHS Foundation Trust has admitted full breach of duty, and that the error which caused Ms Hynes death was the insertion of the heart valve the wrong way, as part of ongoing legal action taken by the Mrs Hynes family.

In a narrative conclusion, coroner Ms Dilks said she was led to believe that on the balance of probabilities, the valve was remounted incorrectly, and against manufacturers’ instructions.

She also confirmed that once the error had been made there were missed opportunities to identify and correct the damage done by that error, which ultimately led to Mrs Hynes’ loss of life.

She is now to write to the trust to express her concerns that this issue may have potential to cause future problems, and will request that certain areas be addressed.

Legal action will seek ‘civil redress’ for loss and support General Medical Council investigations

At the conclusion of the three-day inquest this afternoon, the family’s lawyer Nicola Evans, of medical negligence specialists Hudgell Solicitors, said that legal action would continue to be pursued.

She revealed that the General Medical Council (GMC) had been in touch with her to confirm they are considering investigating the circumstances of Mrs Hynes death.

She said: “Ever since the tragic and avoidable loss of Sheila in April 2015, her devastated family have battled for answers as to how such a serious, life-taking mistake could be made, and for those responsible to be held to account.

“The inquest scope was extended to give the coroner the ability to thoroughly investigate the circumstances of Sheila’s death by consideration of a breach of a person’s human right to life.

“We welcome today’s narrative conclusion, and the coroner’s comments about writing to the Trust to prevent further situations like this in future. We certainly think there is a need to look carefully at training and use of surgical equipment.

“However, Mrs Hynes family remain of the view that all evidence was not clearly considered, and we will now assist them in seeking civil redress for their loss, and will support the General Medical Council (GMC) with any ongoing investigations.

“Surgeons are aware of the catastrophic results of mistakes such as this, and in this case it has cost a much loved mother, grandmother and great grandmother her life.

“Let us not forget that Sheila’s death was a result of a grave surgical error by Mr Shah. That has been admitted in our legal negotiations, and during this inquest this week.

“I would like to express my thanks to the family for their bravery through such testing times.”

Family vow to continue fighting for justice after inquest concludes

Mrs Hynes daughter, Jan Hopper, of Haltwhistle, Northumberland, says losing her mother in such tragic and unexpected circumstances has ‘destroyed her life too’.

She said: “No matter how many times we hear the reasons for what went wrong and why, we will never be able to overlook the fact that my mother died simply because a highly experienced surgeon didn’t take enough care. It is beyond belief.

“We don’t even know whether to believe the valve was reinserted upside down. We feel Mr Shah was simply incompetent, unsupervised and made a mess of our mother’s heart.

“It was a week after the error, and after my mum had died, that the hospital finally admitted to us that the heart valve had been put in upside down.

“Mr Shah initially told us that he didn’t know why she was bleeding so badly after the operation and indicated they were putting her on life support to give her heart a rest and to prevent it having to work too hard given what it had been through. He never mentioned putting it in upside down.

“It is shocking and can’t end here. We won’t allow it and we’ll continue to fight for justice for mum.”

Mrs Hynes had the operation to replace the aortic and mitral valves after suffering from shortness of breath. The operation was aimed at relieving her symptoms and extending her life, the inquest heard.

Mrs Hopper said her family had encouraged her to have the operation done, adding: “We told her that she had nothing to worry about and that she was going to the Freeman Hospital which was known for its transplants and heart surgery.

“Now we wish we’d never encouraged her as she’d still be with us now.”

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22/06/2017 No Comments

Five-figure damages for mum left afraid to have more children due to injuries caused by hospital after giving birth

Doctors Hospital Corridor Nurse Pushing Gurney Stretcher Bed


A young mother has spoken of her heartache of feeling too afraid to have more children and extend her family due to medical staff leaving her with long-term injuries following the birth of her only child.

The woman, who has asked not to be named and was represented in a successful medical negligence legal case by Hudgell Solicitors, suffered a second degree tear when she gave birth to her son and needed stitching afterwards.

However, errors made during the repair procedure left her in pain for months – needing extra repair surgery months later, and told she faced the threat of serious further injury should she have another child naturally in the future.

The errors, which were admitted by the Hospital Trust involved – caused not only physical pain and suffering for the woman – but also psychological trauma going forward, as she has felt unable to face giving birth again.

‘It has impacted on my life and future family plans’

“The poor treatment I received after giving birth to my son has impacted on my life and my hopes for a bigger family,” said the woman.

“I was told that if I was to have another baby after the repair surgery, it was recommended I had a caesarean because otherwise I could end up with a fourth degree tear and possibly need a colostomy bag for life. It wasn’t something I thought I’d need to consider so quickly, as I had the coil fitted.”

Despite this, the woman fell pregnant just before her son’s first birthday – leaving her facing what she now says was ‘the hardest decision’ of her life.

“They said I could have had a caesarean at 37 weeks, but I’d already missed out with bathing my little boy and taking him for walks due to the pain I’d been left in after his birth,” she said.

“If I’d had a caesarean, I would have been in the same boat again, but with a scar on my stomach. I also really couldn’t face the idea of more surgery.

“I also knew that if I went through a natural birth, I faced the possibility of needing a colostomy bag for the rest of my life and a worse tear. I couldn’t have had my son climbing on me either and there would have been a risk of infection.

“I didn’t know what to do. It was the hardest decision I have ever had to make. But I felt I had no choice but to have an abortion. I felt I had to have it and I was heartbroken and gutted. My son was still so young and I was not ready.

“I should never have been in a position where medical reasons influenced a life decision like that though.”

Woman believed injuries were common after birth until seeing specialist

Even now, the woman needs further surgery to fully repair the damage caused by the initial errors in 2013. At present, however, it is not something she is ready to face.

“I don’t want to take it any further until my son is older because I couldn’t stand the pain,” she said.

“The more scar tissue they cut away, there will be nothing left to stitch up.”

The woman says that in the initial days after giving birth to her son, she assumed she was simply suffering as many mothers do after having a first child.

Having remained in hospital for a number of days due to losing blood, she was still in pain and bleeding when she returned home, something midwives said could be painful for some time and would take time to heal.

And having read online that pains could last between 6-8 weeks, she assumed everything would return to normal in time.

However, with pain persisting more than two months later, and unhappy with how the stitching looked, she went to see her GP, who sent her to a gynaecologist as her stitching had not healed.

“It wasn’t an easy birth as I had an epidural but I could still feel everything,” she said.

“If they had listened to me in that delivery room when I said I could still feel pain, they could have maybe done it right the first time and this could have been avoided.

“Initially, when I came out of hospital I was really sore, but just thought that was normal for someone who’d had a tear and been stitched up. As far as I was concerned, I assumed I would be sore because I’d just been stitched, so I didn’t think much more of it. The midwife suggested a few ways to soothe it but pain was expected.

“I was still bleeding and it was still tender at 10 weeks. Then I looked in the mirror and it looked like a wound. It had healed but it hadn’t joined together.

“My GP looked at it and said the perineum is usually 3cm but mine was only 1cm. I was referred to see a gynaecologist and that was when I was told I needed more surgery and the significance of my injuries became apparent.”

Going forward, the woman says she can’t at present see herself having more children to give her son a brother or sister.

“I couldn’t bear the thought of going through similar complications again,” she said.

“If I could have more children and guarantee there wouldn’t be more complications, I’d like to have more, but it is so difficult given what I have been through,” she said.

“My sister and I were really close growing up and I hate to think of my son on his own without siblings. But I don’t feel I can give that to him and I feel robbed.”

Five-figure damages offered after birth claim highlighted failure to follow guidelines

The woman took legal advice through Hudgell Solicitors, and as part of the case against the Trust which runs the hospital, it was alleged that a specialist trainee had not been adequately supervised when repairing the tear.

It was also alleged that they had failed to apply appropriate technique and failed to note the tear hadn’t been repaired correctly.

It was also alleged the trust failed to follow the National Institute for Health and Care Excellence (NICE) guidelines.

The trust admitted “on the balance of probabilities” that it failed to apply the appropriate technique, that it had failed to follow the NICE guidelines and that it was likely the repair was not carried out to a satisfactory standard and caused the subsequent symptoms and need for further surgery.

It denied the allegations about supervision of the specialist trainee and failure to note it hadn’t been repaired correctly, but offered the woman a five-figure damages settlement, which she accepted.

‘New mums should be encouraged by midwifery staff to question any changes to their body’

Solicitor Nicola Evans, who represented the woman in the case, said: “It is often the case that someone who suffers injuries such as this simply cannot face further surgery when they have a young child to care for.

“This lady is in that situation now and it is all avoidable if the repair is done correctly in the first place.

“Pregnancy and labour is always difficult for the first time. No first-time mother knows what to expect or quite how their body is going to recover afterwards. When faced with injury, initial thoughts are often simply to get it fixed as quickly as possible so that they can enjoy their new bundle of joy.

“In my client’s case, it was a substandard repair which, again, she did not know what to expect and just assumed that the problems she had after the repair were to be expected. This was not the case.

“New mums should be encouraged by midwifery staff to question any changes to their body and where necessary request examination by either the midwives or their GP, to ensure that problems are not left unnecessarily.”

The woman said Nicola was a great support to her throughout her claim.

She said: “She has been brilliant and really kept me up to date with everything as my legal case progressed. I am glad she was able to get admissions of error from the trust and I hope lessons are learned, both by the hospital and in terms of awareness of other mothers to ask questions over their care.”

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16/06/2017 No Comments

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