Coroner’s attack on gran Lyn’s poor care in hospital

Coroner’s attack on gran Lyn’s poor care in hospital

Coroner’s attack on gran Lyn’s poor care in hospital

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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.”

Comments (8)

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8:34pm Fri 10 Jan 14

runwellian says...

Perhaps it is time we started suing the Department of Health (not the hospitals) for failure to provide adequate staff in hospitals.

It is also time the fat lazy consultants were forced to work shift wok in the same way the GP's are being hounded to work 7 days a week.

Consultants use hospital facilities to earn money from private patients, no wonder appointments take so long to come through and are then cancelled at short notice … probably because a private patient needs the slot!

My thoughts are very much with the family±
Perhaps it is time we started suing the Department of Health (not the hospitals) for failure to provide adequate staff in hospitals. It is also time the fat lazy consultants were forced to work shift wok in the same way the GP's are being hounded to work 7 days a week. Consultants use hospital facilities to earn money from private patients, no wonder appointments take so long to come through and are then cancelled at short notice … probably because a private patient needs the slot! My thoughts are very much with the family± runwellian
  • Score: 15

10:19pm Fri 10 Jan 14

Mikkel1 says...

There are FAR Too many fat cats in hospitals, and pruning Big time.

I lost my Last wife to Big C less than 36 hours after an 'EXPERT' diagnosed it, and gave her Months, not years to live. This was NOT in Basildon, but Norfolk.
There are FAR Too many fat cats in hospitals, and pruning Big time. I lost my Last wife to Big C less than 36 hours after an 'EXPERT' diagnosed it, and gave her Months, not years to live. This was NOT in Basildon, but Norfolk. Mikkel1
  • Score: 0

9:55am Sat 11 Jan 14

whataday says...

The Govt. should get rid of most of NHS management and listen to what doctors, nurses and patients are saying and remedy the shortage of staff who actually do something by the way of care for patients.
The Govt. should get rid of most of NHS management and listen to what doctors, nurses and patients are saying and remedy the shortage of staff who actually do something by the way of care for patients. whataday
  • Score: 1

6:42pm Mon 13 Jan 14

Kim Gandy says...

Why was the communication poor? More language barriers? Overworked staff? No proper shift handovers? I'd like to know why.

When I hear of a senior nurse giving out meds in a hospital, reminded by a porter that she had left her keys behind, saying she didn't understand the word "key" and couldn't comprehend what he was trying to tell her, I worry. The woman was giving people tablets..for God's sake.

Yes, it did happen. Not in Southend but it is an example of poor communication. Some hospital staff do not speak proper English. NOBODY should be working in this country without speaking the language.

It doesn't happen in other countries.

And before the resident Racism Detector starts spouting. That's FACT. It's called REALISM. Something you are not familiar with LL. Nobody cares so don't bother.
Why was the communication poor? More language barriers? Overworked staff? No proper shift handovers? I'd like to know why. When I hear of a senior nurse giving out meds in a hospital, reminded by a porter that she had left her keys behind, saying she didn't understand the word "key" and couldn't comprehend what he was trying to tell her, I worry. The woman was giving people tablets..for God's sake. Yes, it did happen. Not in Southend but it is an example of poor communication. Some hospital staff do not speak proper English. NOBODY should be working in this country without speaking the language. It doesn't happen in other countries. And before the resident Racism Detector starts spouting. That's FACT. It's called REALISM. Something you are not familiar with LL. Nobody cares so don't bother. Kim Gandy
  • Score: 1

7:06pm Wed 15 Jan 14

25sammy25 says...

My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly.
My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly. 25sammy25
  • Score: 0

7:10pm Wed 15 Jan 14

25sammy25 says...

Mikkel1 wrote:
There are FAR Too many fat cats in hospitals, and pruning Big time.

I lost my Last wife to Big C less than 36 hours after an 'EXPERT' diagnosed it, and gave her Months, not years to live. This was NOT in Basildon, but Norfolk.
Mikkwl1 - I joined the Echo tonight after reading about Mrs O'Reilly's death. I had a similar experience as her but survived. This was also in a hospital in Norfolk. I totally agree, it's time to cut out the middle men (pen pushers) and employ more staff for patient care. My sincere condolences at the loss of your wife.
[quote][p][bold]Mikkel1[/bold] wrote: There are FAR Too many fat cats in hospitals, and pruning Big time. I lost my Last wife to Big C less than 36 hours after an 'EXPERT' diagnosed it, and gave her Months, not years to live. This was NOT in Basildon, but Norfolk.[/p][/quote]Mikkwl1 - I joined the Echo tonight after reading about Mrs O'Reilly's death. I had a similar experience as her but survived. This was also in a hospital in Norfolk. I totally agree, it's time to cut out the middle men (pen pushers) and employ more staff for patient care. My sincere condolences at the loss of your wife. 25sammy25
  • Score: 0

1:55pm Thu 16 Jan 14

P.Joyner says...

25sammy25 wrote:
My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly.
Congratulations for surviving the C.Diff bug, my mother wasn't so lucky and died a week after contracting it.
This was after a routine bowel op at Basildon hospital.
She was just dosed up on morphine and left to die, ballooned up with septicaemia.
The joke of the matter was the coroner refused to put anything about C.Diff on the death.certificate. This would have been another case brushed under the carpet, I refused to collect the death certificate until they put it as a cause of the septicaemia.
This was 5 years ago and it saddens me to see the hospitals are still putting patients lives at risk over something so easily avoidable with good cleaning practices.
[quote][p][bold]25sammy25[/bold] wrote: My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly.[/p][/quote]Congratulations for surviving the C.Diff bug, my mother wasn't so lucky and died a week after contracting it. This was after a routine bowel op at Basildon hospital. She was just dosed up on morphine and left to die, ballooned up with septicaemia. The joke of the matter was the coroner refused to put anything about C.Diff on the death.certificate. This would have been another case brushed under the carpet, I refused to collect the death certificate until they put it as a cause of the septicaemia. This was 5 years ago and it saddens me to see the hospitals are still putting patients lives at risk over something so easily avoidable with good cleaning practices. P.Joyner
  • Score: 1

9:16pm Tue 21 Jan 14

Minicooperfan says...

25sammy25 wrote:
My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly.
actually, less than 10% of C. Diff cases are hospital acquired. Most patients with this bacteria that gets admitted into hospital got it from the community
[quote][p][bold]25sammy25[/bold] wrote: My heart goes out to the O'Reilly and sincere condolences for their loss. There are too many mistakes being made in our hospitals now, whether it be lack of staff, language problems or what, there should be no excuse. I found myself in the same situation as Mrs Reilly after a bowel operation, at a different hospital I may add. I was lucky and survived after quite a time in oblivion. I would be interested to know if this lady died of the same infection as I myself caught, called CDIFF, which can be fatal. This virus is mostly caught when in hospitals. Obviously sterilization and cleanliness is missing and it's time hospitals came up to the mark of ensuring patients safety. RIP Mrs O'Reilly.[/p][/quote]actually, less than 10% of C. Diff cases are hospital acquired. Most patients with this bacteria that gets admitted into hospital got it from the community Minicooperfan
  • Score: 0

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