Blackpool Victoria Hospital boss quizzed over failings that led to Valerie Kneale's fatal attack being missed
The Chief Medical Officer at a hospital where a stroke patient was so violently sexually assaulted she died from her injuries say improvements have been made to care offered by staff.
Dr Neil Hartley Smith, Chief Medical Officer at Blackpool Teaching Hospitals addressed the inquest examining the death of 75-year-old Valerie Kneale at Blackpool Victoria Hospital in November 2018.
Coroner Alan Wilson sitting at Blackpool Town Hall heard troubling evidence about gaps in record keeping, staffing pressures and unanswered questions surrounding Mrs Kneale final hours.
Nurses and doctors giving statements admitted they had little or no memory of caring for Mrs Kneale with some unable to recognise her or recall crucial details of her treatment.
One nurse described feeling “extremely guilty” at not remembering Valerie, acknowledging that they were “extremely short staffed” at the time.
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Expert witnesses highlighted serious documentation issues with missing neuro-observations, absent end-of-life notes and suggestions that some records may have been lost or destroyed.
Dr Neil Hartley Smith, Chief Medical Officer at Blackpool Teaching Hospitals, said: “We are seeing an improving trend with the record keeping.
“One specific item that's looked at in those audit notes is lose papers. We are one of the last trusts in the country using papers we are moving towards a digital solution for that.
“There should have been hourly neuro observations taken. Intentional rounding chart was part of the audit we don't want any gaps in care to exist.”
Coroner Alan Wilson asked: “Would you say likelihood seeing gaps of this nature in the records is significantly minimised now?”
Dr Hartley Smith replied: “Yes I'd say it's minimised. There will be that contact point with the patient and observations.
“We have had other ongoing projects within the stroke unit looking at deteriorating patients. Far more checks and balances are now in place and more options available to seek further advice on a patient since 2018.
“The only speculation I may have for the gaps at that time was an intention to help comfort the family.”
Dr Hartley Smith detailed the SWAN model they use for end of life care to patients.
He said: “These things are so important to a patient and loved ones - we want it to be as good as it can be.
”SWAN model is an extra layer of support after someone is going through the dying process.”
“The SWAN model stands for signs, words, actions and needs. There is no one set model for everybody. The patient is reviewed on a 2 hourly basis by HCA and a minimum of every 4 hours by a nurse.”
Concerns were also raised about ward security with evidence that doors were sometimes left propped open and about whether early warning signs of Valerie’s deterioration were acted upon.
The coroner pressed Dr Hartley Smith on whether similar failures could occur today.
Dr Smith insisted improvements had been made since 2018 with greater staffing levels, digitalisation of records and more robust systems for raising concerns.
He said: “We encourage all staff to report when something has gone wrong. We have specific training for that.
“In 2018 the stroke unit was viewed as an entire unit now it has two separate teams - the acute stroke team and the staff have a well rehearsed set of skills to prepare for a transfer to Preston and Thrombolysis and recovery rehabilitation team.”
However, the inquest heard that investigations into training, escalation of concerns and accountability remain ongoing in regards to the trust.
The case continues to raise difficult questions about whether Valerie Kneale’s care met the standards her family and the public had a right to expect.
Retired clerical assistant Mrs Kneale from Poulton was admitted to Blackpool Victoria Hospital after suffering a stroke at home.
As a result of a fall when suffering the stroke she also fractured her leg.
When arriving on the ward her family told the hearing she was ‘chatty’ but her speech was not 100%.
Just four days after she was admitted she passed away.
A post mortem revealed she had suffered violent internal and external injuries as the result of a sexual attack.
The attack is thought to have happened during her first night in hospital and she was surrounded by family the remainder of the time.
Heavy blood loss was not picked up despite her worstening condition which doctors said was a slow bleed in the brain.
The hearing continues.