Walsall Manor Hospital trust admits failings over patient's death
The hospital trust that runs Walsall Manor has admitted a series of failures in the 48 hours leading up to the death of a 52-year-old woman taken to A&E.
Jacqueline Holland, from Walsall, was taken by ambulance to the hospital on December 7 last year having suffered with vomiting for the previous three weeks.
She was transferred from A&E to the Acute Medical Unit (AMU) and later to another ward. She died two days after being admitted after going into cardiac arrest.
At her inquest yesterday a pathologist gave the cause of death as cardiac arrhythmia due to kidney failure as a result of established severe scarring of the liver.
However it heard the condition – known as hepatorenal syndrome – was not diagnosed by doctors at the hospital.
Mr Kevin Duce, representing Walsall Healthcare NHS Trust, which runs the hospital, told the coroner there were eight separate admissions made by his client.
They included:
A failure to recognise she was deteriorating and showing sepsis ‘triggers’ which required action.
There was no ‘registrar to registrar’ referral when Ms Holland was transferred to AMU.
Once at the AMU she was not clerked – or processed – for eleven hours.
Mr Duce said: “The inquiry within the trust disclosed a failure to follow the hospital’s escalation protocol for a high National Early Warning Score.”
Mr Duce made the submissions at the start of the inquest at Oldbury which is due to conclude today.
He added: “We do not at this stage need to examine whether these were individual or systemic failings. That will become clearer when we hear all of the evidence.”
The inquest heard Ms Holland had a history of drinking but had not had a drink for five weeks before her death.
Ian Foster, who had lived with her in Crowberry Close, Walsall, said she had twice nearly died in recent years from burst stomach ulcers. At Walsall Manor she was treated by a junior doctor for possible pneumonia.
Dr K Shalan, a consultant who reviewed Ms Holland the day before she died, said how she presented with hepatorenal syndrome was ‘very atypical’ and that she had ‘normal renal function on admission.’
He added: “It was absolute shock when I saw the post-mortem report that this was hepatorenal function. You would not think that looking at this person.”
Mr Foster told the coroner Ms Holland had been a “very bubbly, very happy and very caring person.” The inquest continues.
