Hospital neglect contributed to patient’s death inquest told

Julie Barton, who had Down’s Syndrome, died at the Lovely Lane site on April 27, 2019, at the age of 54, after being admitted there as a patient.

She was taken to hospital by paramedics after developing symptoms of back pain following a fall in her Longford home.

But as a patient, it was found that she had developed an infection and sepsis, but the medication administered to her was ‘not appropriate in type, dose or administration method’.

An inquest into Julie’s death was held at Warrington Coroner’s Court, sitting at Parr Hall, and this concluded that there was a ‘gross failure to provide to her basic medical care, which was causative of her death’.

A statement prepared by Julie’s sister, Anita Cairns, which was read out at the inquest, stated: “We are heartbroken she died. We loved Julie so much, and our lives are empty without her.”

The hearing heard that despite having Down’s Syndrome, Julie was able to maintain a good quality of independent living thanks to family support.

In March 2019, she suffered an accidental fall at her home and it was initially thought that she had not suffered significant injury, but she then developed symptoms of back pain.

Two x-rays taken in April confirmed that Julie had fractured her vertebra and pelvis.

Her pain got so bad that on April 21 her family called for paramedics who rushed her to Warrington Hospital, where she was admitted.

Blood tests were carried out on her arrival which indicated she had an infection and sepsis.

Warrington Hospital

A decision was made to administer intravenous antibiotics to Julie on the basis that this was likely to be the most effective means of delivering medication to tackle her infection.

Initial efforts to achieve intravenous access were unsuccessful, and a decision was made to provide oral antibiotics rather than escalating efforts to enable this medication to be given intravenously.

The inquest heard that the antibiotics administered to Julie were ‘not appropriate in type, dose or administration method’ to treat her infection.

Repeat blood tests were not undertaken to help monitor the progress of the infection and Julie’s response to antibiotic medication.

According to a statement from Brenda Hughes, Julie’s sister, her family was told following a CT scan on April 23 that Julie was ‘medically fit for discharge’.

The following day however, she noticed that Julie’s breathing had become increasing noisy, but was told by a doctor that her chest was fine.

One hour later, Julie took a turn for the worse. Her noisy breathing returned and she was vomiting.

Through this acute deterioration, it was identified that her infection had persisted, despite treatment.

Julie was admitted to the intensive care unit where her condition continued to deteriorate, and she died on April 27.

“My main concerns about Julie’s treatment are that she was completely failed by the health service provided by Warrington Hospital,” Brenda said.

“The correct dosage of drugs was not given to her and blood tests were not taken regularly, which I believe would have been major factors in preventing her death.”

Peter Sigee, assistant coroner for Cheshire, concluded: “Julie’s death was caused by a natural disease process, namely sepsis caused by pneumonia, and it was contributed to by neglect.

An inquest into Julie’s death was held at Warrington Coroner’s Court, sitting at Parr Hall

“There was a gross failure to provide basic medical care to Julie while she was in a dependant position which was causative of her death.”

The inquest also heard from Dr Lisa Lang, doctor for adult safeguarding, mental health and learning disability at Warrington and Halton Hospitals Trust (WHH), who spoke of the lessons learnt following a ‘comprehensive investigation’ carried out following Julie’s death.

These included developing a trust-wide strategy for patients with learning disabilities to ‘respect and protect their rights’ and making learning disability a trust-wide quality priority assisted by a steering group.

WHH will also take part in an annual national learning disability improvement audit and recruitment will include a specialist nurse with learning disability and safeguarding experience.

Dr Lang also said that there will be a trust-wide increase in awareness and knowledge in relation to the needs of patients with learning disabilities.

Following the conclusion of the inquest, Simon Constable, chief executive at WHH, offered his apologies to Julie’s family.

He said: “The trust would like to offer our deepest and heartfelt sympathies to Miss Barton’s family; our thoughts are with them at this difficult time.

“Following a review of the care afforded to Miss Barton, the trust undertook a thorough investigation.

“The investigation highlighted that Miss Barton did not receive the high standards of care we always strive to achieve, and for this we apologise unreservedly to Miss Barton’s family.

“The trust is committed to ensuring that lessons are learnt to improve care and to learn from this experience.

“Since the very sad death of Miss Barton, the trust has introduced a number of recommendations, including appointment of a specialist nurse and the development of a protocol to support patients who have a learning disability and may require additional support from our teams.”