Family's shock discovery of their loved one dead in his hospital bed
BLUNDERING hospital staff left a family at the bedside of their loved one for nearly 10 minutes before telling them he had died.
Heartbroken Karen Dobbins wept as she revealed the horrific mistake during the inquest into the death of her beloved partner, Andrew Dale.
Mr Dale, 62, of Albert Road, Stubbington,Â had been admitted into Queen Alexandra Hospital on January 5, 2017, after being struck byÂ a rare auto-immune disease, which caused his muscles to waste away and his health to decline.
But the retired groundsman died in a freak accident at the Cosham site 19 days later after rupturing his spleen in a fall by his bed.
Doctors and nurses failed to spot the fatal bleed, which led to him having a heart attack little more than four hours later which killed him.
However, Ms Dobbins said when she and her family were called to the hospital on the morning of January 24, they were oblivious to her partner's fate.
Speaking at a two-day hearing in Portsmouth Coroner's Court, the emotionalÂ 58-year-old, of Fareham,Â told how she stroked her long-term partner's hand and spoke to him, thinking he was only in a coma.
Holding back tears, she said: '˜We thought he was still alive. His hands were warm.
'˜We were talking to him thinking he was alive even though there were no monitors on the wall.
'˜Then five minutes later two nurses came in and started talking about what happened during the night and that he went for a CT scan.
'˜I asked them 'what happens now?' because they didn't actually say anything. Then they said he has passed away.
'˜They were stunned that I had asked that question.
'˜I was in shock. I had no idea.Â I just cried.'
The distressing error is one of several hospital shortcomings highlighted during the court hearing, and which sparked a serious investigation by QA.
The inquest into Mr Dale's death heard how the '˜keen cyclist' had been '˜battling' with illness for almost a year before his death.
Then in December of 2016, his health declined sharply. Family members told the court how he had become '˜frail' and '˜weak'.
At one point, during one of Mr Dale's daily cycleÂ rides, he lost the use of his legs and collapsed.
He was rushed to QA where doctors battled to diagnose his condition.
Nurses assessed him and concluded he was too weak to walk unsupported and would need at least one person to help him to the toilet at all times.
Hospital policy also required them to monitor what Mr Dale ate and when.
However, the inquest heard that nurses failed to log his food after January 11 '“Â 13 days before he died.
During Mr Dale's stay in hospital, his weight plummeted from 47.8kg to 42.2Kg, something his family said they raised with hospital staff, worriedÂ he was getting '˜thinner and thinner'.
The court heard how days before his death, Mr Dale had started treatment forÂ Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg'“Strauss syndrome.
As part of his treatment, doctors prescribed him 40mg of the blood-thinner clexane to reduce his risk of developing blood clots in his legs while in hospital.
OnÂ the morning of his death, at 2.15am,Â Mr Dale fell while using a commode by his bed, cuttingÂ his head.
Ward nurses found him on the floorÂ with a small pool of blood around his head andÂ alerted the on-call night team, made up of junior doctor Dr Stephanie Kent and trainee advanced clinical practitioner, Cassie Moore.
The pair arrived in 40 minutes '“ 10 minutes later than hospital targets for night calls '“Â and began treating the '˜confused' and '˜agitated' Mr DaleÂ for hisÂ head wound.
Dr Kent said she conducted a '˜thorough' full-bodyÂ assessment of Mr Dale and could see '˜no obvious sign' of any other injury.
She added when she pressed on his abdomen, he showedÂ '˜no signs of pain' of discomfort, something that would normally happen if a patient had a serious internal injury.
Mr Dale's blood pressure began to drop and heart rate increased, she said, while his skin felt '˜clammy'.
A CT scan was requested to check for bleeds on the brain, which came back negative.
However, blood tests came back at 5.20am which showed a drop in haemoglobin levels.
Fearing he may have been developing sepsis, Dr Kent gave Mr Dale some fluids to bring up his blood pressure and antibiotics to counter a possible infection.
An hour later he had a heart attack and died.
The court heard how an internal investigation by the hospital showed Dr KentÂ failed to '˜follow protocol' andÂ '˜escalate' the issue to more senior doctors.
Pathologist Dr Adnan Al-Badri conducted a post-mortem examination and was '˜shocked' to find a small tear in the spleen '“ an injury more commonly associated with a high-impact trauma like a car crash.
Although finding a small bruise on the abdomen, Dr Al-Badri was certain this appeared after death.
He added a possible diagnosis of sepsis was '˜not unreasonable', and said: '˜I have never seen someone have a ruptured spleen from a fall. That would have been at the bottom of my diagnostic list.'
He added the use of clexane meant the wound kept bleeding and that fluids to raise Mr Dale's blood pressure had increased the rate of blood loss.
He said doctors should have '˜considered' internal bleeding following the blood result but was unsure whether surgery at that point could have saved Mr Dale.
He said the cause of death was an inter-abdominal haemorrhage due to a ruptured spleen caused by trauma to the abdomen.Â
Coroner Lincoln Brookes recorded a narrative verdict and said: '˜Such an injury is rarely seen from this type of fall and Mr Dale initially had no obvious pain that medics would normally expect from such a condition.
'˜At 5.20am the blood results gave cause to consider thisÂ diagnosis but this did not happen. Nor was the case escalated in accordance with the hospital's policy.
'˜Had this occured there may have been a very small chance of preventing the death through the critical care/surgical teams.'
'˜WE DON'T WANT ANYONE ELSE TO GO THROUGH THIS'
HOSPITALS need to have online '˜patient portals' for loved ones to check on their relatives, aÂ grief-stricken family has demanded.
The loved ones ofÂ Andrew Dale, who died while at Queen Alexandra Hospital, said health sites need to modernise the way they communicate with relatives.
It comes after doctors failed to tell the family Mr Dale had died beforeÂ they visited him, on January 24, 2017. Speaking after an inquest into Mr Dale's death had concluded, his eldest daughter, Vanessa Dobbins-Dale, 29, said: '˜We don't ever want any other family to go what we have gone through.'Â Â
HOSPITAL OFFERS AN UNRESERVED APOLOGY
HOSPITAL bosses have apologised '˜unreservedly' for a series of blunders during the treatment of Mr Dale at Queen Alexandra Hospital.
Dr John Knighton, medical director at Portsmouth Hospitals NHS Trust '”Â which runs QA '”Â stressed significant improvements had been made following the death of Andrew Dale in January 2017.
HeÂ said: '˜I unreservedly apologise to the family and friends of Mr Dale and send my sincere condolences.Â
'˜It is deeply distressing to all of us when the care we give doesn't meet all of the high standards we strive to achieve.Â This is why we undertook a detailed and thorough review of the whole of Mr Dale's care, to identify and ensure we acted on any areas for improvement.
'˜All of the recommendations and learnings identified have been completed.Â These include enhanced education, training and advice about the management of deteriorating patients for all staff groups, patient observations and escalating cases to senior colleagues.'
One of the hospital's shortcomings was a failure to escalate news of Mr Dale's deteriorating conditions to more senior staff.
To tackle this, the trust hasÂ introduced the Time to ACT quality improvement initiative which aimed to improve the care of all deteriorating patients.Â
The scheme, which was '˜working well', has improved how patients are monitored and treated at night.
'˜This has been developed by a cross-speciality working group and signposts staff to next steps. We are already seeing significant improvements from this project,' Dr Knighton added.