Junior doctors at Blackpool Vic ignored hospital rules about sepsis - contributing to the death of a grandfather from Cleveleys.
William Shaw, 69, died at the hospital on May 11 2018 from multi-organ failure and septicaemia.
He had been brought in by ambulance at 5.15pm on May 2 with abdominal pain and sickness, and was showing signs of an infection.
He should have been placed on the Vic’s sepsis pathway, but the junior doctor who saw him decided not to.
At Blackpool Town Hall last week, coroner Clare Doherty said that junior doctors involved in the early care of Mr Shaw felt that their own personal judgement was more important than following the hospital’s strict rules in cases where sepsis may be a risk.
She raised a similar issue with the hospital following a previous inquest in which a man died after not being placed on the pathway when he should have been.
She said: “In relation to staff failing to trigger the sepsis pathway, I was concerned that there may be a risk of future deaths if this continues.
“The Trust has put many measures in place to train and educate staff in the importance of adhering to the Trust’s protocols.
“Hearing the junior doctors’ evidence, they believe their judgement is paramount and while hospital protocols are helpful tools, they are not mandatory. I think further discussion with staff by the Trust may produce more cohesive and better protection.”
At 9.10am on May 3, the day after Mr Shaw was admitted, a senior doctor ordered an urgent CT scan should be carried out as he suspected he was suffering from peritonitis - an infection of the abdomen.
But this was not done until shortly after midnight on May 4, revealing a bowel perforation believed to have been caused by a large ulcer.
He was taken in for a laparotomy to repair the severe perforation at 2.30am.
However, Mr Shaw’s condition continued to decline and he died seven days later.
Ms Doherty said: “Mr Shaw was always going to need complex surgery which was not without risk, however the failure to do a CT scan increased Mr Shaw’s risk of mortality from 28 per cent to between 72 and 98 per cent.
“There were several gross failings to provide medical attention, notably a failure from professionals to communicate clearly with each other and ensure that a CT scan was carried out.
“There was a failure to provide care which, on the balance of probability, directly caused Mr Shaw’s death.”
The coroner also raised concerns that, in the hospital’s own internal investigation, one of the doctors involved in Mr Shaw’s care was not sought for comment, as he had left the Trust.
A number of key pieces of evidence were also not provided to the court until the last minute.
Ms Doherty said: “I do wish to make it clear that if in future a case arises where procedures are not followed, particularly related to the sepsis pathway, I will consider a regulation 28 letter and in doing so I will consider not just sending it to the Trust, but sending it to the Care Quality Commission.”
A regulation 28 letter from another coroner had already been sent to the hospital regarding staff failing to properly fill in patient notes, she said.
Sue Ann Shaw, Mr Shaw’s daughter, said: “I would like to thank the coroner, Clare Doherty, for leading the very thorough investigation into the circumstances leading to my dad’s death at Blackpool Victoria Hospital.
“My dad was a very proud, hardworking man who was socially active and enjoyed life. My brother and I are deeply saddened by the thought that he could still be alive to enjoy his family and leisure time had his condition been diagnosed and treated sooner.
“It is very distressing to think that those whose responsibility it was to advocate and care for him let him down when he was at his most vulnerable and this is something that we will need to come to terms with.
“My dad certainly suffered before his death. He lost his life and the reverberations have been felt by all who knew him. I’m sure the professionals involved have also experienced distress as a result.
“We hope that Blackpool Victoria Hospital will address the issues identified by the coroner so that another preventable death and all the pain associated with such a tragic event does not happen again.”
Professor Mark O’Donnell, Medical Director at Blackpool Teaching Hospitals NHS Foundation Trust said: “We offer our deepest condolences to the family in this very tragic incident.
“Our thoughts and full support are with them at this difficult time.
“A full investigation into this case was conducted by the Trust and a number of learning points were identified.
“An action plan has been put in place and lessons learned have been shared with our staff and Mr Shaw’s family.”
The hospital refused to say whether any action had been taken against doctors responsible for the failings that led to Mr Shaw’s death.