The devastated family of a mum who was 'crying in agony' begged nurses for help but they failed to administer medication on ten different occasions which contributed to her death.
Samantha Elizabeth Rawstron, 48, who had a number of different medical conditions, including Type 1 diabetes, was admitted to Blackpool Victoria Hospital on November 10, 2019.
Samantha, who relied on her sister Caroline as her carer, had become drowsy and her family suspected that she may have a urinary tract infection, Lancs Live reports.
Samantha, who was born in Blackpool, was prescribed several medications but on ten occasions, an inquest heard how medics failed to administer it intravenously after considering that she was unable to swallow tablets.
Just eight days after being admitted to hospital, she tragically passed away with her sister by her side. An inquest held at Blackpool Town Hall on July 11 heard a statement from Samantha's sister Caroline who shared that she 'begged' nurses to help her sister who was 'clearly suffering'.
The day before her sister died Caroline said she was 'ready to wheel the bed down to A&E as we were desperate for help'.
Caroline revealed that she 'asked the nurse repeatedly' to give her sister some IV fluids, after a period of 12 hours with none, 'until she completely avoided me'. She added that another nurse involved in treating her sister, an agency worker from Russia, told her she worked 'as both a dentist and a doctor' in her home country.
On one occasion Caroline was told blood tests had not been carried out as the 'wrong bottles' had been used to take the sample. After her sister died Caroline recalled: "We felt like screaming. We had spent the weekend hitting our head against a brick wall. What had gone wrong? I felt like I'd failed her. I knew something was wrong and nobody listened."
After Samantha's death Blackpool Teaching Hospitals NHS Foundation Trust carried out an investigation which concluded that several aspects of Samantha's care 'fell far below a reasonable standard'. The hospital admitted medics had failed to manage Samantha's consistently low blood pressure and failed to administer medication.
A separate expert report added that 'lots of things could have been done differently and there is much to be learned from this case'. Hospital staff failed to appropriately monitor Samantha and there were lapses in care relating to fluid management and administration of medication.
A post mortem revealed the cause of death was multi organ failure due to bronchopneumonia and organ damage due to diabetes. The coroner decided against making a report to prevent future deaths after hearing the hospital trust had made several improvements following Samantha's death and intended to carry out a second review.
Returning a conclusion of natural causes, Assistant Coroner Victoria Davies said: "In the early part of her admission Samantha was appropriately recognised as having a UTI, sepsis, acidosis and constipation. There were errors in her care in part in relation to the administration of her medication.
"On November 12, the nurse appropriately withheld oral medication but there was a failure to consider alternative routes of medication. As a result of 10 omissions of sodium bicarbonate she developed hypernatremia.
"It more than minimally contributed to her death. There was also a failure to manager low blood pressure and lapses in care around her fluid management but I do not find these contributed to her death."
Pete Murphy, Executive Director of Nursing, Midwifery, Allied Health Professionals and Quality at Blackpool Teaching Hospitals NHS Foundation Trust, said: “I want to send my deepest condolences to Samantha’s family and friends and apologise for the actions that were clearly missed and could have been better as part of her overall care.
“I also want to reiterate the comments made by the Coroner and confirm that we have reviewed this case and implemented changes as a direct result of it. The trust is working hard to improve and ensure our services are caring, safe and respectful and making progress every day.”
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