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Coroner’s attack on gran Lyn’s poor care in hospital
A MUCH-LOVED mother and grandmother died after doctors at Basildon Hospital failed to notice she had serious infection, an inquest has ruled.
Lyn O’Reilly, 57, suffered the fatal infection after a bowel operation, at the hospital, but senior consultants failed to pick it – mainly because they were relying on inexperienced junior doctors.
An inquest into her death, on August 31, 2012, was told the junior doctors, looking after her had only been in the job for four weeks. For some of her time in hospital, a single junior doctor was left alone to care for 130 patients on the night shift – something which, even now, remains standard practice at the hospital.
Yesterday, Essex coroner Caroline Beasley-Murray called for a ban on junior doctors being left unsupervised at night.
The inquest was told “a window of opportunity”
to save Mrs O’Reilly was missed and her medical notes were “a shambles”.
Mrs Beasley-Murray, said: “There were very serious failings in the post-operative care Mrs O’Reilly received at Basildon Hospital.”
The inquest heard junior doctors had raised concerns about her condition, but these had not been acted upon by consultants.
Junior staff were given only minimal support, day or night time by more senior doctors.
Communication between nurses and doctors was also poor, another reason why the deterioration in MrsO’Reilly’s condition was not acted upon.
The coroner was told poor notes meant it was not clear if a senior consultant had reviewedMrs O’Reilly’s case on the morning of her death. It appeared she had “probably not” been reviewed.
Mrs O’Reilly was found collapsed in the hospital toilets, after days of complaining of being in pain. Nurses performed CPR for 25 minutes, but were unable to save her.
Apost-mortem examination found fluid in her abdomen, caused by an abscess which had burst and led to the fatal infection.
Independent expert Jonathan Refson said: “If a senior registrar had reviewed Mrs O’Reilly on August 30, they would have thought something was not right.
“Personally, I would have arranged an urgent CT scan. If that had been done, she would have had a different management plan. Acting first thing in the morning would have made a difference.”
Mrs Beasley-Murray recorded a narrative verdict and added: “The standard of documentation was woefully inadequate.”
She added she had already raised concerns about similar short comings with medical notes in past cases and planned to write a detailed report to hospital managers, outlining how she thought they needed to improve.
LYN O’Reilly’s family paid tribute to her after the inquest.
Relatives fought back tears as senior Essex coroner Caroline Beasley-Murray severely criticised Basildon Hospital for failing to give her adequate care.
After the inquest, her brother, Dave O’Fallon, said: “She was a caring woman who wouldn’t hurt a fly.
“She didn’t deserve the treatment she got.”
Her mum, Rita O’Fallon simply said: “She was my best friend.”
MRS O’Reilly’s death has already led to some changes at Basildon Hospital.
These include, the employement of more nursing staff at weekends and over bank holidays, better support for junior staff and improved note taking.
Medical director Celia Skinner said: “I offer my condolences on behalf of the trust.
“We will learn from this. Basildon is a hospital which has been under considerable scrutiny over the past few years.
“As a consequence, we have done much to improve the care and make it safer.”
A new electronic programme has been put in place to better spot patient deterioration and standardise practice.
Staff workloads are regularly reviewed and junior doctors are nowgiven a five day induction course – longer than the national minimum – and more learning time before going on the wards.
Senior staff working practices have also been changed to given them more time to see patients on the wards.
Coroner Caroline Beasley-Murray, said: “It is clear that the hospital has put in substantial efforts in preparation of this inquest. The action plan is to be commended. The court has been gratified to hear of such changes.”
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