A 97-year-old great grandmother died after being forced to wait 40 hours for stitches while junior doctors argued over who was responsible for her.
Josephine Lakin fell out of her bed and cut her head on a short-staffed ward and was only discovered when a cleaner found her in a cramped side room.
It then took doctors at Nottingham’s Queen’s Medical Centre four days to she had also broken her knee in the fall.
Her devastated family have now received an apology from NHS bosses after they admitted there catalogue of failures in the lead up to her death on October 16, 2011.
Mrs Lakin had initially been admitted to hospital on October 10 with an infection.
However, the day after she was admitted she fell out of bed and cut her head.
It took medics almost two days to stitch up the cut because of a ‘disagreement’ between junior surgeons and they also failed to realise that she had broken her knee.
She died two weeks later.
A post mortem examination revealed her cause of death to be congestive cardiac failure and the fracture to her left leg.
The widow’s devastated family pushed for an investigation into the death and this week received a letter of apology from Nottingham University Hospitals NHS Trust, which runs the hospital.
Her relatives have now condemned the level of care she received at the hospital and urged for elderly patients to be treated with more dignity in future.
Granddaughter Mandy Flint, 43, from Bilborough, Nottinghamshire, said the family first knew something was wrong when they got a midnight phone call from the hospital about the fall.
She said: We could not understand it.
She had been unable to walk for the past three years and had never fallen from her chair at home.
She didn’t have the strength to move herself, so how could she have fallen? That was all I was thinking.
Mrs Lakin was admitted to the hospital with an infection but fell out of bed the next day. She cut her head but it took medics two days to stitch it up because of a ‘disagreement’
But it was when I saw her on the hospital ward that the shock set in.
She looked like she had been beaten up. Both of her eyes were black and she had a large cut on her head.
She didn’t deserve to die like this. You think you can have faith in the way people are treated in hospital – but you can’t.
They let her down. And we’ve had to live with the mistakes.
We don’t want any more people to be treated the way she was.
I always thought that she would have lived to 100-years-old had it not been for this fall.
Since her death we have found it difficult to cope with what she went through.
We are not interested in compensation, we just want to make sure that no one else goes through what she did.
The report also found there was a lack of a proper assessment of the risk she would fall from her bed.
When interviewed, nurses admitted that the ward was understaffed, too reliant on agency workers, and that record-keeping and communication were poor.
An inquest into Mrs Lakins death recorded a verdict of accidental death.
The Trust has since issue an ‘unreserved’ apology and admitted failing to meet required care standards.
In a letter to the family chief executive Peter Homa said: I deeply regret that Mrs Lakin died in such circumstances and that there were so many areas of our care which fell below the standard that we would expect.
I apologise unreservedly for the shortcomings in care Mrs Lakin received from the Nottingham University Hospitals NHS Trust.
The Trust made a number of recommendations in the wake of its investigations – including a thorough review of communication protocols and operating procedures on the ward.
It also ordered staff draw up clear lines of responsibility for the assessment and stitching of wounds sustained in falls.
The use of agency staff was recommended to be kept to a minimum, and the review also said staff should be reminded of the need to keep clear and detailed notes.
Nottinghamshire Coroner Mairin Casey said she felt the Trust had improved its record on falls from hospital beds.
She said: Nottingham University Hospitals NHS Trust has shown a raised awareness of the issue of falls within their hospitals.
They have taken careful note of the difficulties they have faced and how they have been addressing those difficulties, looking the issues generally and as part of a learning process when patients have fallen resulting in serious injuries or even death.
Over this two-year period we have seen huge improvements in the trust’s efforts to minimise falls including work done to formulate clear policies and procedures and risk assessments.
Nottingham’s Queen’s Medical Centre has apologised to Mrs Lakin’s family and says that it has made a number of improvements since her death
Mr Homa said: ‘I wish to reiterate the Trusts deepest apologies to Mrs Lakins family that she fell when in our care and sustained serious injuries.
‘The cause of the fall and wider concerns about Mrs Lakins care were thoroughly investigated, and the findings and our improvement actions shared with her family in March 2012.
‘We appreciate that some patients, particularly those who are frail and confused patients, are at high risk of falling in the unfamiliar surroundings of a hospital.
‘We have a very active programme across our wards to reduce the number of falls and associated injuries.
‘The Coroner is satisfied with the steps the Trust is taking to prevent falls. Indeed, the Coroner has commended our work and improvement, and continues to take a keen interest in these matters.’
Source Mail Online
