Hospital failures Archives

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

Posted on 21 March 202427 March 2025 by Sarah O'Sullivan

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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Inquest concludes after Suffolk postmaster’s tragic hospital death

Posted on 16 June 202130 March 2025 by Sarah O'Sullivan

An inquest at Suffolk Coroner’s Court in Ipswich, conducted by Mrs. Catherine Wood, has heard evidence regarding care and service delivery issues while investigating the tragic hospital death of a 73-year-old man who had been admitted for treatment of a fractured hip.

Background

The patient, Barry Jefferson, had worked for many years alongside his wife Sarah at their Post Office Stores business in Thurston, near Bury St Edmunds. They were close to finalising plans to sell up and spend more time with family, including their young grandchildren.

On 17 August 2020, Barry tripped at home and fractured his right hip, which had previously been replaced. After relatively straightforward surgery was performed on the periprosthetic fracture at West Suffolk Hospital on 20 August, he was slowly recovering in the orthopaedic ward and appeared to be doing well.

Bloating and swollen abdomen

Placed in a side room due to a positive MRSA test, by 27 August Barry was unwell with nausea and vomiting. During the August Bank Holiday weekend, he told nurses he felt bloated and had a swollen abdomen. The nursing team consulted doctors on call, who prescribed medication for bloating.

Over the course of the bank holiday weekend, Barry became increasingly unwell. Despite repeated escalation from the nursing staff, he was only reviewed by very junior doctors, going five days without review or input from senior clinicians. In addition, following clinical reviews, documentation was often poor or missing, and there appeared to be a lack of understanding of the changing clinical picture.

On Tuesday 1 September, a review by the advanced nurse practitioner pointed to a possible infection, source unknown. At this stage, Barry had not been reviewed by a senior clinician since before the weekend, and there had been no proper investigations into his abdominal distension. Antibiotics and fluids were administered intravenously, but Barry became more unwell overnight and began vomiting.

A consultant conducted a further review in the afternoon and, suspecting a possible bowel obstruction, ordered nil by mouth and an abdominal X-ray. The X-ray that afternoon showed distended loops of small bowel consistent with an obstruction.

Following the X-ray and referral to the surgical team, Barry suffered further deterioration, and an emergency call was activated. Probable irreversible organ failure was suspected when he did not respond to resuscitation treatment by the emergency team. Sadly, he died a short time later.

Care and service delivery issues

Following Barry Jefferson’s death on 2 September, ultimately due to cardiac arrest, a Serious Incident Report was completed by West Suffolk NHS Foundation Trust. This identified a number of care and service delivery issues and pointed to several root causes.

“The report highlighted a series of delays in recognising deterioration in Barry’s condition during that fateful bank holiday weekend and tardiness in seeking senior reviews and investigations,” explains Tees Law, acting for widowed Sarah Jefferson.

“A more timely response earlier in the weekend might have led to a different outcome in this case. Establishing why things went so badly awry has not been helped by a repeated lack of documentation by the junior doctors who reviewed Barry, it being recorded during the inquest that the documentation fell far below what would have been expected from a junior doctor.

“Review by a senior clinician should have occurred sooner, with particular emphasis over the bank holiday weekend. This could have led to an urgent surgical review, with investigations such as the abdominal X-ray and nasogastric tube insertion occurring sooner.

The inquest heard from a senior member of the Hospital Trust who confirmed that the Trust had found that a lack of appropriate senior review over the Bank Holiday weekend led to a failure to recognise Barry’s deterioration, late investigation, and late treatment.

There was further found to be an inconsistent approach to the handover of patients out of hours, leading to poor communication between teams, failure to review or monitor for deterioration, and delay in escalation of a sick patient. The lack of a Sick List meant that patients who required close monitoring were not routinely monitored or reviewed.

Measures implemented

Following the Trust’s internal review, a number of measures have now been put in place, including a revised handover within the surgical division, use of a Sick List during handovers for general surgery and orthopaedic teams, development of a Standard Operating Procedure for a revised handover process, as well as shared learning in respect of escalation of patients and the importance of documentation to junior doctors.

A second ortho-geriatrician to the surgical division is also being recruited to work towards the Trust’s goal of every orthopaedic patient receiving a review by a senior doctor Monday to Friday, with senior surgical review out of hours as needed.

“Sarah Jefferson is grateful to the Coroner for the thorough investigation into Barry’s death. Hopefully, following the Hospital Trust’s findings and the measures that have been implemented since Barry’s death, the incidence of failures to escalate the response to clearly deteriorating patients will have been greatly reduced.”

Timely treatment might have saved devoted wife and grandmother

Posted on 26 October 202030 March 2025 by Sarah O'Sullivan

A retired wife and grandmother tragically died in hospital after multiple opportunities were missed to administer appropriate treatment that could have saved her life, an inquest at the Suffolk Coroner’s Court in Ipswich concluded after a two-day hearing.

HM Senior Coroner for Suffolk, Nigel Parsley, heard that 61-year-old grandmother Karen ‘Jane’ Winn from Northwold near Thetford, Norfolk, died at the West Suffolk Hospital in Bury St Edmunds on Monday 15 April 2019, four days after being diagnosed with a suspected urinary tract infection by her GP.

Jane was prescribed antibiotics by her GP on 11 April, but she returned next day as she was by then very unwell. She was referred straight to hospital and admitted the same day. That evening a senior medical consultant diagnosed Jane’s condition as haemolytic anaemia, a serious blood disorder.

Haemolytic anaemia depletes oxygen-carrying red blood cells and medical staff identified that Jane was at risk of developing a deep vein thrombosis, which can result in a life-threatening pulmonary embolism if a blood clot reaches the lungs. So, correct intervention at that point was vital for Jane.

Once the haemolytic anaemia diagnosis had been made, the immediate response should have involved blood transfusions plus ‘prednisolone’ steroids and folic acid. Anticoagulant medication was intended to be given, subject to the result of a repeat blood test to assess internal bleeding risk.

Anticoagulant delayed

Jane initially received only blood transfusions and antibiotics. Not until 14 April were steroids and folic acid administered, whilst no prophylactic anticoagulant was given until 15 April, by which time it was too little, too late to disperse any blood clots that had formed during the previous 72 hours.

An automated venous thromboembolism (VTE) risk assessment warning system is embedded into the electronic patient monitoring for all patients. Disturbingly, this VTE system was manually overridden 58 times between 12 and 15 April, despite Jane’s increased risk of blood clots.

Sadly, soon after transfer to the intensive care unit and an hour after her first and only dose of anticoagulant, Jane suffered a fatal cardiac arrest. This was the outcome that Jane’s distraught husband Brian and the wider family had feared and one they believe could have been avoided.

“We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly,” says a close family member. “The right diagnosis was made, but life-saving medication was given too late, despite repeated reminders. Our hope now is that lessons learned will prevent the same thing happening to anyone else.”

Significant blood clots

The primary cause of death, a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes, was confirmed at post-mortem. Widespread pulmonary emboli in the lungs and significant blood clots in veins of the upper leg were both evident.

In summary, the Coroner concluded that Jane’s death resulted from the progression of a naturally occurring illness, contributed to by the non-administration of medication to prevent blood clots despite being earlier identified as essential for her treatment; the latter amounted to neglect.

Tees Law, acting for the bereaved family, comments: “A venous thromboembolism risk assessment is mandatory for all patients admitted to hospital and should be completed within hours of admission. It was wholly unacceptable for the assessment alert to have been overridden 58 times over those four days. The Coroner’s finding of neglect acknowledges the total failure to give Jane basic medical treatment that would ultimately have increased her chances of survival.”

Read the full story here.

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