Failures In Care Eventually Identified In Serious Untoward Incident Report After Medical Negligence Lawyers Investigated

A woman whose mother died at West Middlesex Hospital says more must be done to implement the NHS’s “Duty of Candour” after an internal investigation into her mother’s death was only carried out after she took legal action.

Angela Richards, from Whitton, was 78 years old when she was admitted to West Middlesex Hospital on April 29, 2014 following a fall at home. However she died just three days later from respiratory failure, due to fractured ribs which had injured her lung.

Her daughter Caroline Brand instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care and treatment her mother received from Chelsea and Westminster Hospital NHS Foundation Trust, which is responsible for care provided at West Middlesex University Hospital.

An inquest at the West London Coroner’s Court, which concluded on Thursday, March 17, heard evidence from medical staff involved in Angela’s care that there were failures to adhere to the management plan, to keep accurate and timely medical notes, and of communication between the medical staff in charge of Angela’s care.

The coroner delivered a narrative conclusion saying: “The deceased was admitted to hospital and surgery was planned for internal fixation and fracture. During the course of her stay in hospital, there were missed opportunities to carry out timely and adequate medical reviews. The deterioration in her condition in the early hours of May 1, 2014 and the significance of the deterioration in her condition went unrecognised”.

The NHS Litigation Authority (NHSLA) acting on behalf of the Chelsea and Westminster Hospital NHS Foundation Trust denied it was liable for Angela’s death in October 2015. However, a Serious Untoward Incident (SUI) Report by the Trust itself and shared with the family in November 2015 identified multiple failings including a lack of “ownership, communication and decision making leading to the patient not having timely interventions, nor medical review on escalation of her deteriorating condition”.

The Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm.

The SUI report also found there was a failure to escalate Angela’s death for investigation until Irwin Mitchell notified West Middlesex Hospital of the family’s intention to take legal action.

The SUI report concluded that Angela should have been prioritised for theatre and a chest drain to re-inflate her lung should have been inserted earlier into her admission. The report also found that hourly observations were not carried out by the nursing staff as planned and that number of individuals had the opportunity to alter Angela’s course. In total, four recommendations were made to try to improve care by medical staff.

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“We would like to thank the coroner for providing Angela’s family with the opportunity to hear from medical staff about the events leading up to Angela’s death. Angela’s family had many questions about the treatment she received and the evidence heard at the inquest has provided some answers.

Angela’s family is obviously devastated by her death. She was the main carer for her husband, a lower limb amputee, and was active and independent. Her daughter Caroline has however been incredibly frustrated to find that, before we became involved, the Trust had not carried out a formal internal investigation into her mother’s death.

“To find out that there were mistakes in Angela’s care was extremely disappointing and raises questions over the process of investigating incidents. The Duty of Candour was implemented for a reason and it is important that the NHS takes it seriously.

“The NHS needs to ensure it learns from its mistakes but it can’t do that unless it acts with transparency when things go wrong. The family hopes that lessons will now be learned to improve care for others.” Anna Vroobel - Associate Solicitor

Caroline, from Middlesex, said: “My mother’s death was very upsetting for our family but to then discover that there were mistakes in her treatment has made it incredibly difficult for us to come to terms with.

“My mother was independent and active and my father relied on her for his care. He has now had to move out of the family home he shared with my mother because of the assistance he requires with his day to day living.

“I’m glad I took legal action as without my lawyers we may never have found out what actually happened to my mother. It is some comfort to hear from representatives at West Middlesex University Hospital that measures have been put in place to stop similar events happening again, but it saddens me to think that it took my mother’s death to make those changes happen.”