A coroner has attacked Royal Preston Hospital after a patient died due to a “gross failure of basic care”.
Retired postman John Billington, 70, suffered a fatal head injury when he fell in a ward at the hospital, because doctors and nurses failed to spot he was at risk.
Dr James Adeley recorded a verdict of “accidental death caused by neglect” – only the second time in a decade that such a ruling has been reached at the city’s coroner’s court.
And he is now writing to the Lancashire Teaching Hospital Trust’s chief executive expressing his concerns for patient safety.
“It is difficult to express just how basic a failure of care this was,” he told the inquest.
“I don’t accept this was unavoidable – this was entirely avoidable.”
Staff from the hospital were in court for the “neglect” verdict. One of the doctors in the case apologised to Mr Billington’s family after the hearing and was told: “Shame on you.”
The inquest heard Mr Billington, of Hoghton Lane, Higher Walton, was admitted to the RPH in April with a suspected bowel problem after suffering vomiting and abdominal pain.
The pensioner, who suffered from renal problems, became increasingly dehydrated because staff failed to keep proper checks on his liquid intake and output. Over five days he lost more than 10 litres of fluid.
Repeated concerns raised by his family – his daughter-in-law was an advanced nurse practitioner – about his condition went largely unheeded.
With his blood pressure having dropped due to a lack of fluid – and because he was suffering from an untreated urinary infection – he tried to stand in the ward and collapsed, fracturing his skull and suffering bleeding on the brain.
Mr Billington was found lying on the floor by his bed and died from the head injury more than two weeks later.
In his summing up Dr Adeley said both doctors and nurses failed to note the deterioration in his condition because proper monitoring, requiring “basic maths,” had not been carried out.
Staff had tried to justify this by saying the patient notes were kept elsewhere in the ward. But the coroner said: “To justify this lack of adequate clinical care because you can’t walk to where the documents are, or ask a nurse for them, is a very poor excuse.
“There are two possible causes that I find proved on the balance of probabilities to have caused John Billington’s fall.
“The first is the dehydration he sustained due to serious failures to manage his fluid balance, resulting in a fall in blood pressure on standing. The other was the urinary tract infection which remained untreated by the medical staff for some unexplained reason.”
That failure to treat the infection was, he said, “very poor practice in elderly patients suffering from a degree of chronic renal failure”.
He also accused the hospital of failing to heed multiple warnings from Mr Billington’s family and a failure to conduct a risk of falls assessment.
“It is difficult to think of a more basic example of care than ensuring someone who can’t drink is provided with fluids,” he said.
“I find the test for neglect, that this is a gross failure of basic care to a person in a dependent position which caused his death, to be made out on the relevent standard of proof.
“Consequently my conclusion is that John Billington died an accidental death caused by neglect.”
He added that the findings had “implications as to the standard of clinical risk governance in the trust.”
“The impression that I have gained is that the Trust considers itself to be doing quite well, all things considered, rather than noting and acting upon serious failures to learn from its mistakes and consequently places other patients at risk.”
Mr Billington’s family declined to comment after the verdict was recorded.