Stoke Mandeville Hospital admits multiple failings after woman's death

Mrs Stephens was admitted to the hospital via the emergency services on February 20 and died in intensive care two days later.

Bucks Healthcare NHS Trust admitted that they failed in a number of areas - and a report which has now been published found that Stoke Mandeville Hospital staff missed opportunities during her stay.

Mrs Stephens received an above the knee amputation the previous month and after she became unwell, Mrs Stephens daughter Dawn Saunders raised the alarm.

An ambulance attended her home and the crew requested she attended the nearest emergency department (Stoke Mandeville) in case she required a coronary intervention.

Mrs Stephens was reportedly left on a corridor within the hospital for an hour and a half after a mix-up over her transfer to another ward.

On the morning of February 22, Mrs Stephens condition deteriorated and she experienced a peri-arrest.

The patient died in intensive care after she was transferred to High Wycombe later in the day.

The cause of death was recorded by the hospital as 'myocardial infarction, pneumonia and ischaemic heart disease' however the family believe that sepsis should have been put on the death certificate.

A serious investigation report says there were the following 'missed opportunities':

Feb 20 - To request a Troponin blood test

Feb 20 - To advise the family of the patient's status

Feb 20 - To request a Troponin blood test in light of new information

Feb 21 - To review the ECG and discuss the patient's condition with the cardiology department

Feb 21 - To consider a Troponin and discuss cardiac status

Feb 21 - To re-review the patient and ECG given the increase in respirations

Feb 22 - Two missed opportunities to inform the family of clinical changes

The report also found the following serious service failings:

Feb 21 - No evidence of a clear explanation to family following a senior review on the post take

Feb 21 - To ensure a knowledgeable handover of the patient's experiences in the trust to date

Feb 22 - Failure to use the preferred method to contact the family

Feb 22 - Lack of preparation to receive the family or warn them of events which had a significant impact on the family's emotional distress

Mrs Saunders said: "The way they treated my mother was disgraceful.

"This has been the worst year of my life due to the hospital's complete negligence.

"I think heads should roll and the staff should be re-trained because they are not doing their job correctly."

In a statement Carolyn Morrice, chief nurse at Bucks Healthcare NHS Trust said: "We would, once again, like to express our sincere condolences to the family on the sad loss of their relative.

"We have met with the family on several occasions and have made a full and thorough investigation into the care Mrs Stephens received.

"As a learning organisation we are keen to make sure that any recommendations resulting from this in-depth investigation are fully implemented so we can continue to improve the standard of care we provide for all our patients and their families."