James Craig, 63, of Milbourne Street, died on July 4, 2019, of pneumonia caused by chronic obstructive pulmonary disease (COPD), a progressive lung condition.
Following his death, his sisters, Rosemary Craig and Olga Deal, were horrified to discover doctors had placed a Do Not Resuscitate (DNR) order on his file.
Rosemary, 53, said: “If I had been asked, I would have said no. My brother loved life. He went mad when he thought there was a DNR on his file earlier that year.”
James had been admitted to Blackpool Victoria Hospital on May 24, 2019, with a chest infection following an appointment with his doctor. He was given a round of antibiotics and was discharged on June 7, but was readmitted three days later after his condition worsened.
During his time at the hospital, his sisters say he became increasingly concerned for his own safety, as he told them he had been woken up in the middle of the night by a nurse inserting a cannula into his right arm and attempting to administer medication which was intended for another man on the same ward, who had the same surname as him.
Rosemary, who lives in Belfast, said: “Before he died, my brother kept ringing us and saying he wasn’t getting his medication, or that they were giving him somebody else’s medication, and I was getting really, really worried. I heard arguments in the background every time he was talking to me.
“The day he died, in the morning he was in good spirits. We spoke to him at lunchtime and then at 1.50pm we rang him and asked if a doctor had seen him and he said ‘no, I never see any doctors’.
“At 2pm he went downhill – we couldn’t understand it. He was gasping and gasping for breath. He couldn’t speak. We rang the ward and they were talking about escalating his care, and that the doctor would talk to us. But no doctor talked to us.
"My brother kept gasping for breath. We asked him what was wrong and whatever it was, he couldnt get it out.”
James was last seen by a doctor at 3pm, who Blackpool Victoria Hospital say explained to his sisters that he was ‘not a candidate for intubation and ventilation… or resuscitation’.
But both Rosemary and Olga say they were not informed of this decision.
James’ condition continued to decline, and at 7pm the sisters made an emergency call, which resulted in them being removed from the room.
Rosemary said: “We weren’t even with him when he died. They kept us in the relatives room. When we got to see him, he was already gone.
“They took us out of the ward. We kept getting pushed back and being told not to go in, and we were only allowed in after he had died.”
An inquest carried out last year ruled that James died of natural causes, with no mention of neglect.
An investigation carried out by the hospital in 2020 concluded: “Whilst there is clear evidence of areas in which care could have been improved, it is also clear that this is a gentleman who had become progressively more frail and less tolerant to further respiratory insult. Even with excellent care at all points I can not be certain that he would have survived this admission.”
However, in a letter addressed to Rosemary and Olga in February 2022, Dr Steve Wiggans, director of professional standards and deputy medical director at the Blackpool Teaching Hospitals Trust, apologised for the ‘deficiencies in the care James received’.
He said: “You made it clear that you dispute the details of the events. Whilst it is beyond my remit to adjudicate, what is clear to me is the breakdown in the relationship between you and James, and Blackpool Teaching Hospitals. Together with our failings in communication, this resulted in an environment of mistrust, and you described James being terrified during his admission. I am deeply sorry that James experienced this in his final days of life, and for the impact this has had on you and your family.”
He added: “It is not uncommon for patients with severe lung disease to appear in good health between exacerbations. But with so little reserve, chest infections were a life-threatening risk for James. With each exacerbation and infection, the risk of death increased… we failed to explain that to you and James in a timely manner. That was a missed opportunity, and the failure ultimately prevented James from spending his final hours with loved ones."
He said that the Trust was ‘committed to improving the quality of patient care’, and had made a number of improvements in the respiratory wards and department, including an increased number of consultants and the development of a Respiratory High Care Unit following James’ death.
But Rosemary said: "They promised us there would be big changes around discussion with relatives and keeping them up to date, but the problems are still going on. Every day we’re seeing stories from people who aren’t being informed.
“We have had to live with this for a long time. The ignorance,, the treatment he received. We finally got an apology from the doctors after three years of waiting, and we were told this definitely would never happen again. But it is happening. I thought, no. It can’t go on like this.”
Hospital says “our priority is patient safety”
Pete Murphy, director of nursing, midwifery, allied health professionals and quality at Blackpool Teaching Hospitals, said: “It’s not appropriate for me to talk about any patient in detail to a third party including the media and we don’t have consent from the family to do so in this case.
“What I can be clear about, though, is that our priority is always patient safety and quality of care and we actively encourage staff, patients and their families or carers to come forward with any concerns that they have and discuss them with us. These can be about someone who is being cared for now, either in hospital or the community, or in the past. They will be heard and concerns are taken extremely seriously indeed.
“I will add also that we will be reaching out to Mr Craig’s family following this approach to listen to their concerns in more detail and in particular that they feel there are deficiencies that remain in the quality of care provided by the Trust.”