Urgent review under way at Blackpool Victoria Hospital after tragic death of 36-year-old patient

The systematic “pre-populating" of medical documents came to light during an inquest into the death of 36-year-old Sabina Wood, who was found lifeless in bed after discharging herself from the hospital.

It is the latest negative headline to hit the under-fire Vic, reports Michael Holmes following a joint investigation by the Gazette and The Lead.

In recent years, the hospital has found itself at the centre of several major scandals, including a poison plot on the stroke unit and the unsolved murder of a grandmother.

Two medics are also facing tribunals in the coming days over allegations of dishonesty and sexually motivated misconduct.

Deputy medical director Dr Steve Wiggans told The Blackpool Lead an urgent review of “clinical practice” is underway as a “priority” after a coroner investigating Wood’s death raised the alarm about discharge papers being filled in with guesswork.

He said: “I want to send sincere condolences to Sabina’s family and friends on behalf of everyone at the trust and assure them that improvements in patient discharge summaries are being made, including how additional patient safety concerns and safeguards are incorporated into the online systems which support the care we provide.

“While this work is completed, additional safety instructions have been issued to colleagues and we have shared our learning from the case with other trusts so it is available to make improvements across the local health system.”

Keep updated with the latest Blackpool headlines with our free newsletter email.

Wood, nee Wright, of Wingate Avenue in Anchorsholme, was admitted to hospital last January after spending months in intermittent pain, the two-day inquest, held at Blackpool town hall, was told.

After tests for gallstones, including having a camera put down her throat in a procedure known as an ERCP, the housewife discharged herself against medical advice.

Four days later, she was found unresponsive by her partner, with paramedics confirming her death after being called to her home.

Louise Rae, assistant coroner for Blackpool and Fylde, said in a regulation 28 report to the Vic’s medical director Chris Barben and health secretary Victoria Atkins, written when there is a risk of future deaths unless action is taken, that “during the course of the inquest the evidence revealed matters giving rise to concern”.

She said: “I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge.

“I found that this occurred across disciplines and hospitals given that (redacted) now works at the Royal Preston Hospital as a consultant where I heard the practice also takes place.

“The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients.”

Rae added: “In this case, (redacted) created the document on January 20, 2023 before Sabina underwent the ERCP procedure (three days later).

“This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice.

“The section on ERCP was left blank, intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling.

“As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.”

The coroner continued: “I found it very concerning to hear that speculative information in Sabina’s case was placed on the discharge summary before her procedure took place.

“There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.”

For the latest Blackpool breaking news, sport and culture sign up for our Gazette newsletter.

Despite ruling that Wood died from natural causes, specifically acute haemorrhagic pancreatitis and gallstones, Rae said “there is a risk of deaths in the future from this practice, which is commonplace and neither medical specialism or hospital-specific”.

In a statement, the Vic’s deputy medical director Wiggans said it is “important to note that while the coroner didn’t find that this issue had contributed to Sabina’s death, we acknowledge completely the very serious concerns raised which may be material in other cases”.

On May 31, the Vic formally responded to Rae, saying a new discharge system was being put in place.

“In the interim whilst system implementation is brought to completion, the executive medical director will issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need to take care when pre-populating and that clinicians are not to prejudge any investigation results,” it said.

The Blackpool Lead asked for an interview with the Vic’s new chief executive Maggie Oldham about the culture at the hospital but was told it would breach pre-general election communications guidance.

She will have taken the job knowing about the hospital’s recent history, which has threatened to overshadow the hard and dedicated work of much of its workforce.

High-profile cases

Perhaps the most high-profile case, at least since the slaying of 26-year-old nurse Jane Clough in a hospital car park by her former partner Jonathan Vass in 2010, has been the secret sedating of stroke patients by nurses Catherine Hudson, 54, and Charlotte Wilmot, 48, so they could have an “easy shift”.

A major investigation was opened by police after a student on work experience blew the whistle, with forensic searches of Wilmot’s phone revealing a WhatsApp message reading: “I sedated one of them to within an inch of her life lol”.

That investigation, which saw a number of funerals delayed and post-mortem examinations carried out, then uncovered another shocking incident - the violent killing of stroke unit patient Valerie Kneale, 75, who was so badly abused - possibly sexually - that she bled to death internally.

The suspicious nature of her death only came to light during the police's poisoning probe.

An unidentified healthcare professional was arrested on suspicion of sexual assault, rape and murder but later released without charge.

An appeal on Crimewatch failed to lead to a breakthrough, while the offer of a £20,000 reward from Crimestoppers to find and convict the murderer has so far gone unclaimed.

Kneale's niece, Lisa Jaffier, told the BBC programme her loved ones have been left with a “huge wound that can’t even begin to heal until we find out who is responsible so we can get justice”.

And Lancashire Police’s DCI Jill Johnson declared: “It’s a real worry to the investigation and to the hospital that this could be just one of a number of attacks at the hands of someone who is a predator and who may have committed previous attacks of this nature.”

Alarming incidents

There has been a string of other alarming incidents too, including a “stressed” Vic junior doctor being jailed for groping girls as young as 10 in the street and care worker Hernando Puno, 52, being sent to prison for sexually assaulting five hospital colleagues.

Puno grabbed and slapped some of his victims’ bottoms, Burnley Crown Court was told, and approached others from behind and kissed and hugged them.

One of his victims made a formal complaint to the Vic about Puno’s perverted ways almost a decade before he was finally jailed but “did not appear to be taken seriously”, the court heard.

Puno, who had been told by bosses to “improve his conduct in the workplace”, was told by judge Andrew Jefferies: “You did not heed that warning. You appeared to find your behaviour funny, jokey and not a big deal.

“It was apparent to me that during the course of your evidence you simply did not care or give any thought as to whether any of these women consented to anything you were doing.”

In February, agency doctor Xowi Mwimbi became the fifth Vic health worker to be jailed in just a year after he punched a vulnerable dementia patient.

He claimed he acted in self-defence after being racially abused but a jury saw through his protestations and convicted him.

Judge Heather Lloyd told Mwimbi at Preston Crown Court: “'It is clear you failed in your first duty of care to a patient, which is to do no harm.

“This patient had very complex needs and you ignored warnings over how he should be approached when dealing with him.

“Even a student nurse was aware of the warnings and this would not have happened if this patient had been approached with care.

“After all your years of practice, you thought you knew better.”

Earlier this month, “dishonest” agency nurse Francesca Del-Greco was struck off the medical register after submitting fake timesheets for shifts she never worked to pocket £26,000 in wages.

A Nursing and Midwifery Council panel ruled she “engaged in a premeditated, systematic and longstanding deception”, adding: “Her dishonesty was repeated and sustained.”

Ongoing cases

It comes as another agency medic, Dr Kate Ogah, faces allegations she worked at the Vic at the same time as she was working as a consultant microbiologist at the University Hospitals of Morecambe Bay.

An 11-day tribunal got under way on Monday (June 10) in Manchester, with documents saying: “It is alleged that Dr Ogah received payment from both (hospital trusts) when she knew that she should not be working shifts for both at the same time”.

Meanwhile, a hearing is already being held into allegations that Dr Aloaye Foy Yamah, who reportedly worked at the Vic as a consultant in acute medicine and gastroenterology, “behaved in a sexually motivated way towards” a patient “without her consent”.

Foy-Yamah is also accused of treating the patient, named in documents as Person A, despite having a “close personal relationship” with her.

He also allegedly arranged for her blood to be tested without her knowledge when it was not needed medically and failed to record the test in her medical notes.

A tribunal got under way in December and is set to be held until Friday (14 June). It will then resume from 12-23 August, also in Manchester.

Amal Bose, a heart surgeon at the Vic’s Lancashire Cardiac Centre, was recently charged with sexually assaulting colleagues.

The 54-year-old appeared at Lancaster Magistrates’ Court on Friday after being charged with 14 counts relating to six women.

A hospital spokesperson said recently: “The trust can confirm that a former member of staff has been charged with offences of sexual assault. I want to reassure patients and their families that the hospital remains a safe and caring environment and the provision of services continues as normal.”

Bose’s case was sent to Preston Crown Court, where he will appear on 5 July.