Father-of-Two Died After Medical Staff Failed to Carry Out Life-Saving Blood Transfusion

Specialist Medical Negligence Lawyers Instructed To Investigate

05.12.2014

The family of a man who died after medical staff FORGOT to give him a life-saving blood transfusion have called for lessons to be learned after an inquest heard that a catalogue of failings led to his tragic death.

John Hatfield, 69, from Heworth, in York was under long term treatment for Atrial Fibrillation, a common condition which causes irregular rhythm in the heart and affects around one in 20 adults over the age of 65 years. John’s condition was under regular review and well controlled by the medication he was taking. 
 
John was admitted to York Hospital on 1st May, 2013 and swiftly diagnosed with a gastrointestinal bleed, a side effect of his anticoagulant medication, Warfarin. Yet only eight hours later he collapsed, suffering a cardiac arrest, after medical staff simply forgot to give him a life-saving blood transfusion.

A blood order was placed with the hospital’s blood bank within one hour of John’s admission to the Emergency Department at 16:55, but a decision was made to delay the transfusion and transfer John to the Acute Medical Ward. He arrived at the ward at 22.25, already with chest pains and heart palpitations, and was neither monitored by a nurse, nor ever visited by a doctor. After being left for nearly THREE hours alone on a ward, his low volume of blood caused a cardiac arrest and he never regained consciousness. He died on 8 May 2013 after his life support machine was switched off.

Following today’s narrative verdict, specialist medical negligence lawyers at Irwin Mitchell, representing the family, have had an admission of liability from the Trust and said they are calling for lessons to be learned to prevent the same mistakes happening again.

A Serious Untoward Incident Report compiled by the York Teaching Hospitals NHS Trust found that:
• Communications between departments needed to improve;
• That medical staff, both in the Emergency Department and the Acute Medical Ward, failed to escalate issues to an appropriately senior member of medical staff;
• The tests and observations carried out by staff caring for John were substandard. Patients admitted to the Acute Medical Centre (AMU) needed to be assessed adequately and treated in accordance to their condition; patients with poor test results need to be prioritised;
• The nurse involved from AMU was reported to the Nursing and Midwifery Council and has been dismissed;
• The AMU doctor, a locum, has been referred for further training.

Expert Opinion
The past year has been horrendous for the family and for them to hear that John’s death was completely avoidable has left them devastated once again.

“The incident raises a number of issues which the Trust needs to ensure it addresses in terms of observations of patients and training for its staff so that the same thing cannot happen in future.

“The Trust has carried out an internal investigation and made a number of recommendations in respect of treatment to be provided going forwarded; the family are keen to ensure that these recommendations are implemented.”
Katie Warner, Solicitor
John’s wife, Madeline, 71, said: “We simply cannot conceive how we could lose John so suddenly. One day he is at home happy, fit and able, the next day on a life support machine.

“To find out that he could have, and should have, easily survived leaves us devastated. In our opinion, t is not down to a lack of systems; it is that the systems and protocols were wholesale ignored. John was not failed by one member of staff – he was failed repeatedly by everyone who was responsible for his care. 

“I would like to thank the Coroner for taking the time to investigate what happened to John – it has taken our family over a year of meetings, including insisting that the hospital issue a revised Serious Untoward Incident Report to replace what we felt was a flawed one. We are also grateful for the support from Irwin Mitchell who are continuing to investigate this for our family. I hope lessons are learned to prevent this happening to others in future.”