A 31-year-old man who could not be moved to the emergency room at Blackpool Victoria Hospital because it was full died just one day later.
Now a coroner has warned that understaffing of nurses at the hospital could lead to future deaths.
Matthew Rogers, who had a history of testicular cancer, was admitted to the hospital on July 10 last year after suffering from pain, weakness and lethargy for two days.
He should have been transferred to the emergency room, but the room was full and he was instead moved to a cubicle near the nurse’s station.
The medical registrar was due to assess Mr Rogers on two occasions, but both times was called away.
A critical care plan was put in place at 11.30am on July 11, nearly 10 hours after Mr Rogers was admitted to the hospital. Just 30 minutes later, he was found to be in peri-arrest.
He was transferred to the intensive care unit at 2pm, where a CT scan showed extensive injury to the liver, spleen and bowel. His condition deteriorated, and he died at 10.18pm.
An inquest, which concluded on December 10, found he died from multiple organ dysfunction and pneumonia, obstruction of the blood supply to organs, and ischaemic bowels, contributed to be methadone, cocaine and testicular cancer.
Coroner Andrew Cousins said: “The patient’s observations were not monitored on an hourly basis... It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 3.30am to 6am. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
“Nurse staff levels were below template for the night shift The staffing establishment was for 10 registered nurses. At the time in question six substantive registered nurses were on duty, plus one agency emergency department registered nurse. There were no twilight Nurses or long day registered nurses.
“The serious incident investigation report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing."
He said there was a risk that future deaths could occur, and wrote to Blackpool Victoria Hospital telling them to take action to prevent this.
THE HOSPITAL SAID...
Pete Murphy, Director of Nursing and Quality at Blackpool Teaching Hospitals NHS Foundation Trust, said: “We would like to pass on our sincere condolences to the family of Mr Rogers.
“The Trust has looked closely into the case to ensure we make the necessary improvements in the care we deliver.
“Since July the Trust has made it a priority to review nurse staffing levels across the organisation and has invested heavily to ensure it is doing all it can to address the nurse staffing challenges by ensuring shifts are filled as much as possible with the right number of staff and the right skill mix.
“We have undertaken a regional, national and international recruitment drive and are utilising other suitably trained staff such as Clinical Assistants to undertake observations, transfers and tasks such as cannulation and venepuncture to help support patients.
“We have also introduced daily safe staffing huddles and an intentional rounding process to regularly monitor all patients within the ED department and ensure any issues are escalated quickly.’’