A family’s fight for justice over hospital’s failings

The family of an 85-year-old woman who passed away in early 2022 have spoken out against a Norfolk hospital that incorrectly treated their mother and contributed to her death.

First hospital visit

Marlene Webb was admitted to James Paget University Hospital on 14 December 2021 after she suffered a fall whilst out delivering Christmas cards. Although Ms Webb had a few pre-existing health conditions, she had been independent and mobile, undertaking all her own daily needs in her house, before her fall.

On the day Ms Webb was admitted to the Great Yarmouth hospital, her weight was incorrectly recorded as 77kg, when in fact she was just under 60kg. The blood thinning medication she was on (warfarin) to treat her pre-existing atrial fibrillation was stopped.

The day after, on 15 December, Ms Webb underwent hip surgery for the injuries sustained during her fall. Later that evening though, she began feeling sick and vomited a dark colour. After this, the hospital queried an upper gastrointestinal bleed, but it was deemed unlikely.

Following this, Ms Webb received numerous blood transfusions due to low levels of haemoglobin (found in red blood cells, haemoglobin transports oxygen around the body). She was prescribed blood thinning medication edoxaban to help prevent blood clots. However, the prescription was based on her weight – which had been incorrectly recorded at 77kg – meaning she was being given a higher dose than her body could take. The dosage prescribed to her was 60mg, when it should have been 30mg, based on her weight. Ms Webb continued taking this incorrect dosage for over a month, until one day before her death. 

The side effects of edoxaban can include:

• Can cause individuals to bleed more than usual (as it prevents the blood from clotting as easily)
• Tiredness
• Heart palpitations
• Feeling dizzy or lightheaded
• Nausea
• Stomach pain
• Indigestion

More serious side effects can include:

• Severe bleeding
• Bleeds on the brain

A form completed at the hospital on 23 December 2021 shows Ms Webb’s weight being at 57.75kg. Even at this point, nine days after her hospital admission, this was not picked up and she continued to be given the incorrect dosage of edoxaban. 

Back home

On 28 December, Ms Webb was discharged from hospital. Her medical notes from that day state she had some ‘delirium.’

Back at home, Ms Webb was initially thought to have been making a good recovery, but by 5 January 2022, a GP home visit was requested by her family as her legs were swollen and she seemed very confused. Since she had been home, she was becoming more forgetful and was experiencing more regular falls. This was a stark difference from how she was when she first went to the hospital. In the space of three days, she had four falls. She was also hallucinating and speaking to people who were not present.

Second hospital visit

An ambulance took Ms Webb back to hospital on 18 January 2022 after she suffered a head injury from another fall. Upon her admission this time, her weight was recorded at 54kg. her dosage of edoxaban was still not altered and she remained confused and delirious.

An extract from her medical records on 23 January shows what her mental state was like: “Patient is very confused, shouting and crying at times … declining to drink and eat … trying to remove oxygen at times” … “doesn’t believe we are in hospital. Keeps trying to get out of bed. Doesn’t believe I am a doctor. Wants to phone the police. Explained to pt she is poorly … Does not have capacity … Pt left to calm down for a few minutes.”

On 28 January, Ms Webb was given a blood transfusion. On hospital documents, it is stated that this was necessary due to gastrointestinal bleeding and anaemia. Sadly, Ms Webb did not respond to this treatment and passed away just before 9am on 29 January 2022.

The death certificate of Ms Webb lists the causes of death as:

“I(a) Gastrointestinal Haemorrhage / II Frailty of Old Age / Atrial Fibrillation (On Anticoagulation) / Hypertension”

James Paget University Hospitals NHS Foundation Trust

On the day of Ms Webb’s death, the Trust submitted two incident reports. One of those recorded:

“Patient should not have died due to GI bleed.” The root cause was recorded as: “Edoxaban being prescribed at an incorrect (higher) dose due to incorrect weight recording as of the 28th December 2022. A 7-day delay in starting an alternative to PPI to avoid rebound acid hypersecretion and predisposition to upper GI bleeding.”

The outcome of the second report is recorded as “staff did not adhere to policy. Time management, staffing issues and enhanced supervision of patients led to delays in care provision of blood transfusion.”

These findings were also repeated in the Trust’s Root Cause Analysis Investigation Report. 

The legal claim

Tees’ Medical Negligence team identified several failings in the care the hospital had provided, including a failure to correctly record Ms Webb’s weight; a failure to carry out further investigations for a gastrointestinal bleed despite Ms Webb having exhibited symptoms on 15 December; the prescription of an incorrect dosage of edoxaban and a failure to stop prescribing it on the realisation that it had been over-prescribed. There was also a failure to prescribe alternative medication to prevent gastrointestinal bleeds whilst she was on edoxaban. 

The evidence was that the over-prescription of edoxaban led to her becoming confused and causing hallucinations, suffering from bruising, a general decline in her health and recurrent falls. It also caused or exacerbated the upper gastrointestinal bleed, which caused her death. 

Trust response

James Paget University Hospitals NHS Foundation Trust admitted that an incorrect dosage of edoxaban was prescribed but denied that this caused the injuries complained of. 

The Trust did, however, admit that there was a failure to administer alternative gastroprotection whilst she was receiving edoxaban and that if it wasn’t for this failure, she would not have developed the gastrointestinal bleed and sadly died on 29 January 2022. 

In January 2024, Ms Webb’s family settled their claim out of court against James Paget University Hospitals NHS Foundation Trust.

Impact on the family

Ms Webb’s family said: “Although the Trust admitted fault for the staff’s wrongdoings in relation to the incorrect dosage of edoxaban that was given to our mother, we find it extremely disappointing that they have denied the full impact of this on our mother.

“We think it’s so important to speak out. We were not even able to see our mother when she was in hospital - The Covid-19 pandemic being used as an excuse, despite things having improved significantly by that time. We will never get that time back which could have been so important for us to see her and raise our concerns if we had seen her.  

“We found it very difficult to find out how our mum was doing in hospital and were not kept informed, we kept telling ourselves that she was in the best place, but we do not believe she was, had we been told what was happening and how upset our mum was we could have told the doctors that there was something seriously wrong. We were not told that mum was in her last hours and therefore we were not all by her bedside when she passed. The hospital responds that they are learning, which just isn't good enough, they failed to get the basics correct and their neglect contributed (if not caused) the demise of our beloved mum.

“As a family, we now meet up more than we did before which our mum would have loved, mum was the life and soul of a party and I'm sure many people have fond memories of her. We cannot put into words how this tragedy has affected us all and find it difficult to deal with especially being robbed of time in her last moments.

“We are devastated by the actions of the JPH and we cannot get our mum back, we want people to be made aware that mistakes are being made and that if anyone feels something isn't quite right with their loved ones care shout from the rooftops for a second opinion, we would hate for another family to go through this trauma.  We would also like to thank Tees who were excellent from the outset.”

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