Blackpool Hospital says lessons learned after hip fracture patient dies in tragic circumstances

Changes have been implemented at the Blackpool Teaching Hospitals Trust following the death of a 78-year-old man from gastroenteritis, an inquest heard.

Retired barrister Roy Burgess, from Lytham, died at Blackpool Victoria Hospital in January after rushed back there for a second time from Clifton Hospital in St Annes following bouts of vomiting.

On the second occasion, he had suffered a cardiac arrest after a rapid deterioration in his condition and was declared dead on arrival.

Mr Burgess had initially been admitted to the Vic in December after suffering a hip fracture in a fall at home.

Following treatment for that, he was sent to Clifton Hospital for rehabilitation but several days later, began vomiting and was taken to the emergency department at the Vic, where he was prescribed with fluids and anti-sickness medication by Dr Mark Collingwood.

Dr Collingwood told the inquest at Blackpool Town Hall that, if Mr Burgess had come in from home, he would have kept him at the Vic, but decided he had a better chance of a bed at Clifton, where there was the expectation of a further medical review.

As it was a weekend, however, a doctor at Clifton was only available on-call remotely and when Mr Burgess began vomiting again, this time more severely, the night after his return from the Vic, it was the remote contact to which nursing staff had to turn.

On the advice of the on-call medical registrar, an ambulance was called but by the time paramedics arrived, Mr Burgess had suffered a cardiac arrest, from which he never recovered.

Dr Sam Guest, who heads the emergency department at the Vic and has carried out a review following the case, said there had been a lack of clarity as to why Mr Burgess had been sent to the Vic after his initial bout of vomiting and that handover procedures had been tightened up since.

Now, rather than going straight to the emergency department, he would have gone through a new medical assessment centre, but Dr Guest didn’t feel there would have been much change of management of the case anyway.

Another amendment to handover procedure is electronic links with Clifton from many wards at the Vic, with notes sent with patients where the electronic option is not available.

Dr Collingwood said he had been genuinely shocked when he heard about the rapid deterioration in Mr Burgess’ condition and Dr Guest said he supported the decision to send him back to Clifton.

“Looking at the notes, I don’t feel that decision was inappropriate,” he said.

“I can’t think of any treatment that could have been given in the emergency department that he wasn’t given at Clifton Hospital.”

Cause of death was confirmed by independent pathologist Dr Neil Papworth as gastroenteritis.

He added that underlying conditions of ischemic heart disease, chronic kidney disease and the fact he was still recovering from a hip fracture would have made Mr Burgess more susceptible to illness.

Ms Rae returned a narrative conclusion based on the circumstances of Mr Burgess’ death.