Pat Dawson 'had been fit, healthy and well until very shortly before her admission to hospital'
Medics left Pat Dawson to die and failed to attempt CPR after checking the wrong patient's records on which a 'Do Not Resuscitate' form had been entered. Those records belonged to a man in his 90s.
I am told that grief does not shrink but in time we grow around it and I wish you all the very best in moving forward as best you are able despite your awful loss. Mrs Dawson had a NEWS score of 7 when assessed by paramedics and they called a pre alert to the hospital, so concerned were they with her presentation.
Patricia was not started on a sepsis pathway or an abdominal pathway. Blood tests were taken and, I entirely accept from Mr Dawson, an ECG was carried out. The outcome of that ECG remains unknown as it is not within hospital documentation. Given Patricia’s abdominal pain and the paramedic’s concerns, she ought to have had a specific blood test called venous gas to test for lactates. This test was not ordered.
Patricia was wheeled to the toilet and helped into the toilet. John Dawson stood directly near outside and regularly asked his mum if she was ok. At first and second asking the answer was yes. On third asking there was no reply and Mr Dawson asked staff to enter the cubicle. Unfortunately these were not Patricia’s records. They belonged to a different patient who was both male and in his 90s. Characteristics which clearly Mrs Dawson did not share.
There has been a thorough investigation into the circumstances of Mrs Dawson’s death, for which I offer Ms Cole my sincere thanks. That report highlights a number of areas of substandard care. I endorse in their entirety the findings of this report which includes the following failings: It may well have been that frequent observations showed a declining picture and treatment would have been initiated at an earlier stage. But Patricia’s cardiac arrests superseded that issue and I consider it is therefore not necessary for me to consider whether those issues, whilst important, played a role in her death.
I am satisfied that it is more likely than not that a second resuscitation would have been successful. I reach this conclusion on the basis of her initial very speedy resuscitation within 30 seconds, her underlying baseline of mobility and health, though I accept she had the atherosclerosis which she knew nothing about.
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