Hospital ordered to update procedures to prevent deaths of patients
PUBLISHED: 12:50 16 July 2019 | UPDATED: 15:07 16 July 2019
A widow says she feels as if the death of her husband in a Norfolk hospital has been "swept under the carpet".
It comes after a coroner ordered the Queen Elizabeth Hospital in King's Lynn to update its procedures to prevent the future deaths of patients.
Senior coroner Jacqueline Lake took the unusual step after the QEH failed to meet deadlines to show patients were safe.
It came after an inquest into the death of a man who died after his oxygen supply was cut off while he was being transferred between wards.
In its response to the coroner, the QEH said it has since reviewed its oxygen policy and made improvements.
Its chief executive Caroline Shaw - who joined the hospital in January - has apologised to the family of Peter Knight from Watlington, near Downham Market, who died in the hospital on June 6, 2018.
But Mr Knight's widow Donna, 55, said: "The coroner was concerned and she put a Regulation 28 on because they weren't treating Peter's death seriously. They've abandoned us and swept us under the carpet, it's a disgrace."
An inquest into his death in January heard the 70-year-old retired engineer, who had a terminal lung condition, was transferred between wards without being connected to an oxygen cylinder.
He was left connected to an oxygen pump which did not have batteries, which would not work once it was unplugged from the mains.
Staff overseeing the move between wards did not realise Mr Knight was being starved of oxygen until it was too late. Mrs Lake concluded his death was an accident.
After being told the QEH was reviewing its patient transfer policy, she asked the hospital to write to her when it had updated it.
Mrs Lake made a formal report to the chief coroner after the hospital failed to meet the deadline of March 15, which it had been set to provide details.
"During the course of the inquest, the evidence revealed matters giving rise to concern," it says. "In my opinion there is a risk that future deaths will occur unless action is taken."
Mrs Lake said she was concerned that the policy had not been completed in the timescale set at Mr Knight's inquest.
In response, the hospital said the policy was ratified by its governance committee on May 7. It was rolled out across the hospital last month - a year after Mr Knight's death.
Mr Knight's family say the hospital has not answered their questions over Mr Knight's death.
The QEH was placed in special measures after being rated inadequate in September. The Care Quality Commission said it was unsafe and poorly-led. Findings of an interim inspection are expected to be published later this month.
Mr Knight's death has been referred to the Nursing and Midwifery Council, which is deciding whether to investigate.
QEH chief executive Caroline Shaw said: "I would like to express my sorrow and sadness to the family of Mr Knight for what happened.
"While it may be of small comfort to the family, the hospital has worked hard to learn from what had happened and has put in place processes to increase patient safety along with supporting our frontline staff.
"As we stated to the coroner, we have undertaken the review and implemented the policy to ensure that our patients, and staff, are safe while completing ward transfers. Along with delivering additional oxygen training, for both substantive and agency staff, we have also purchased additional equipment, such as saturation monitors for acutely unwell patients, and introduced a checklist which helps to promote safe ward transfers.
"We did narrowly miss the initial informal deadline for the provision of information to the coroner but we did subsequently meet the legal deadline imposed.
"During the investigation the trust contacted NMC on three separate occasions to keep them informed regarding internal processes, which were being undertaken. The trust is aware that a referral has been made to the NMC and will cooperate with any information required."