Pensioner’s death caused by ‘systemic care failures’

Stuart Maltby (64) died of acute renal failure on 7th November 2012.

He was admitted to Nottingham’s Queen’s Medical Centre (QMC) at 7.54pm on 5th November after being referred to East Midlands Ambulance Service (EMAS) by his GP at 1.53pm.

Nottinghamshire coroner Jane Gillespie told the inquest how EMAS had failed to dispatch an ambulance within two hours as requested by Mr Maltby’s GP because an emergency medical dispatcher had failed to tick a box indicating a two-hour pick up time.

Instead, the system defaulted to a four-hour pick up time.

Ms Gillespie also noted that once en route to the QMC, paramedics failed to administer IV fluids to the pensioner, despite the fact he was accompanied by a hand-written GP note which urged their use.

The inquest was also told how staff on Ward D57 of the QMC failed to give keen gardener Mr Maltby sufficient fluids despite his drug chart prescribing them.

Said Ms Gillespie: “After his admission Mr Maltby should have received five litres of fluid over a 24 hour period. He in fact received two litres.

“Time and again, the lack of fluids being given to Mr Maltby was missed by each and every medical professional charged with providing for his care.

“The reasons given by each witness were a lack of time and the number of patients on the ward that night.

“Each of them said that they should have known that Mr Maltby was not receiving the correct level of fluid, and ideally they should have checked the fluid chart. However, they were simply too busy.”

Ms Gillespie told the inquest a failure to record urine output sufficiently meant early warning scores which dictated whether care needed to be escalated were not updated.

The coroner said a poor nurse to patient ratio, the dependency of the patients, and the physical separation of patients in the side rooms, meant staff failed to conduct and record reliable physiological observations.

Another finding by Ms Gillespie said a robust system for evaluation and re-evaluation of patient progress at a senior medical level was missing.

She added: “This was particularly so at times of staff changeover on ward D57. Had there been a reliable system, it may well have identified patients who would benefit from a senior review, including Mr Maltby.”

Ms Gillespie recorded a narrative conclusion and said: “I do not hesitate to find that there were serious, repeated and systemic failures in respect of the care afforded to Mr Maltby.

“These failures were far reaching and impacted on all aspects of his care, from basic observations and recordings, to a delay in the escalation of his care

and a failure to review his condition by an appropriately senior doctor when necessary.”

Ms Gillespie said changes had been made to care services since Mr Maltby’s death, including the EMAS system, which now defaults to a two-hour pick up time rather than four, and the appointment of a dedicated dispatcher to deal with urgent calls from GPs.

Changes at Nottingham University Hospitals NHS Trust included higher staffing levels and an overhaul of the shift handover system.

In a statement read outside the inquest, a spokesman for Mr Maltby’s family said: “Stewart was a character who made us laugh with his mischievous sense of humour.

“He spent a lot of time caring for others, often to his own detriment. His enthusiasm for gardening, especially orchids, the outdoors and cookery was shared with a wide group of friends.”