BOSSES at Warrington Hospital have admitted to multiple failings in the care of a critically ill mum-of-two who died from multiple organ failure.
Mandy Shaw, aged 46, of Cyril Street, Orford, waited for nearly seven hours to see a doctor and have blood tests despite having a history of chronic liver disease.
She died just over an hour after tests had been carried out.
Dr Paula Chattington, a consultant physician, at Warrington Hospital, Lovely Lane, said there had been a 'breach of procedure' in the care of Mrs Shaw.
At an inquest into her death at Warrington Coroner's Court on Monday, Dr Chattington, and Karol Edge, assistant director of nursing, both apologised to her family.
The inquest heard how a scoring system used to assess the seriousness of a patient's symptoms was used incorrectly, and the amount of times she was observed was not increased in line with protocol.
Her organs were failing but blood tests were delayed, the results only being seen after her death.
Dr Nicholas Rheinberg, coroner for Cheshire, ruled the failings did not cause Mrs Shaw's death.
He said: "I think if the observations had been taken more regularly it would have been realised earlier that Mandy Shaw's condition was deteriorating.
"I find that probably Mandy Shaw's condition on being admitted was irreversible, and that nothing could be done to save her.
"That doesn't exclude the possibility that earlier intervention might have lead to a different outcome."
Mrs Shaw was admitted to Warrington Hospital at 11.23pm on February 15, last year, after being referred by her GP following a week-long illness.
She was not seen by a doctor until around 6.30am. She died at 7.40am.
A long term alcohol problem meant she suffered sclerosis of the liver, although she had been abstinent for three years before her death, and a chest infection cause other major organs to fail.
Her death was ruled as due to natural causes.
FOLLOWING the hearing, the family of Mandy Shaw questioned why she has to die alone after officials admitted they had 'failed' to let them know she had deteriorated.
Relatives including mum Sandra, sister Gemma, and daughter Pepsy, were sent home from the hospital because her condition was not thought to be serious.
Gemma said: "Its disgusting to me that none of us were there when she died.
"In the first Warrington Guardian report the hospital said she had received proper care and made us feel like we were being made out to be liars. this shows that we aren't.'
"Hopefully this won't happen to anyone else.
"She didn't have to die on her own."
Mum Sandra said: "Her children want their mother back and I want my daughter back but at least things have changed.
"We just wanted the truth about what happened but I would like an apology.
"Mandy would have her hand in the air saying 'yeah' if she knew about all the things that have changed."
Senior officials at Warrington Hospital say procedures have been changed since the death of Mandy Shaw.
They told the inquest into her death on Monday a national scoring system to assess symptoms is now used, while staffing and training have been reviewed.
An electronic system to scan documents brought in with patients, such as paramedic reports, has also been introduced.
A spokesman for Warrington and Halton Hospitals NHS Foundation Trust said:
“We have met with Mrs Shaw’s family to say how sorry we are for their loss and to talk through the case and to try to help to reassure them about her care and answer any further questions that they have.
"Mrs Shaw was cared for by nursing staff throughout her time in hospital.
"She was under the care of the medical staff when she suddenly became more unwell and they did everything possible to help her.
"The coroner concluded that Mrs Shaw died of natural causes and our own investigations into the case identified issues and learning in this case which we have addressed, shared with the family and which the coroner was satisfied with.”