A hospital in Scotland has been forced to apologise after a family claims that their failures led to the death of their “really fit” mum.
The family of Jen Clowes has accused Crosshouse Hospital, Kilmarnock of failing to monitor her liquid intake, which led to her being “suffocated” because her liquid input and output were not measured.
Jen Clowes was admitted to the hospital as a kidney patient, but one of her daughters told the Daily Record:
“My mum was not dying when she went into Crosshouse Hospital but died because she went there.
“Had I had any inkling she wouldn’t come back from the hospital I would never have let her go in we would have looked after her at home.”
Jen, 91, was diagnosed in 2020 with a condition called Syndrome of Inappropriate Antidiuretic Hormone which prevents her kidneys from emptying fluid properly. At the time, she had been admitted to the hospital due to the build-up of fluid.
And because of her condition, she was allowed only one litre of fluids a day which included drinks, soups, puddings and gravy among other things and her output needed to be carefully monitored.
However, Jen’s daughter Margaret, a registered nurse explained that she was concerned about the hospital failing to monitor her liquid intake, and her notes instead said to ‘encourage her to drink’.
Margaret said:
“It has been reported that the hospital was instead treating her for infectious exacerbation of COPD because of the breathlessness my mum was experiencing.
“I was constantly phoning Crosshouse Hospital asking how she was and asking what they were giving her for the fluid.
“They told me they were treating her for infectious exacerbation of COPD because of the breathlessness my mum was experiencing.
“But my mum was told years before there was some evidence of her having COPD from years of her being a smoker but she never needed any treatment and hadn’t smoked in 50 years.”
Margaret, a registered nurse, asked to speak to the nurse in charge and explained the family’s concerns.
“As a family, we cared for Mum 24 hours a day. She was terrified of dying and we made sure someone was with her all the time.
“I explained that to the nurse and told her my mum was terrified she was going to die in there and not see any of her family.”
The nurse said Margaret could pop in for half an hour.
“My mum was lying on the bed but she was very mentally alert.”
Later that day a doctor phoned to say she was not responding to treatment so Margaret headed back down to the hospital.
“By the time I got to the hospital, she was unconscious and died later that day without ever regaining consciousness.”
NHS failures
Margaret told the Daily Record that when they got her death certificate it said infectious exacerbation of COPD, but she doesn’t agree with it.
“I could clearly see when she was admitted before with low sodium her sats were 96 per cent, you would never see that with someone who suffered with COPD. She never needed oxygen.
“She kept really fit, She walked to her work almost a mile away and only gave up her job when she was 76. This is not indicative of someone with COPD,” Margaret said.
Medical record concerns
Margaret explained that she became ‘really concerned’ when she asked to see her mum’s fluid balance chart because she could not find it contained within her notes.
“There was only one chart in her notes and it was blank but there was a note which said ‘encourage fluids’.
“My mum was given a cup of tea in the morning, at lunch, then tea in the afternoon and every evening.”
She claimed: “That caused my mum to suffocate to death.
“A cup of tea is 250ml you would measure that and then measure the amount of pee. We did that at home.”
However, it is advised that people with this condition should ‘avoid excess water’.
Margaret explained the severe consequences she would experience if she failed to look after a patient in this way: “If I was looking after someone like her on a ward and I forgot to record it once I would be pulled in and warned if it continued I could expect to be suspended.
“It is a very basic tool but it is a lifesaver. Despite her condition where there was a build-up of fluid, they didn’t monitor her fluid whatsoever. I cannot believe she died of something which had never troubled her before.”
“Syndrome of Inappropriate Antidiuretic Hormone can result in coma and death if it is not treated properly.
“The hospital did not take all the steps to save her life and I think that was purely down to her age, she was viewed as a burden.
“If someone in their forties had the same health condition they would not have died. My mum was not someone waiting to die.”
Hospital apology
The family complained to the Ombudsman who instructed the health board to apologise for failing to accurately complete a fluid chart which they did last month.
But Margaret said: “The lack of fluid chart means they could not possibly know if she had drunk too much. All her symptoms at the end point to her death being down to this.”
Claire Burden, Chief Executive of NHS Ayrshire and Arran said:
“We are sorry that we did not meet the high standards of care that we strive for in NHS Ayrshire &Arran for this patient.
“We have issued a formal apology to the family, and we will ensure that all the recommendations highlighted in the Scottish Public Services Ombudsman (SPSO) report are implemented.
“The outcomes, recommendations and learning from the report will be shared widely to ensure organisational learning is in place also.”
Further reading
Clinical Negligence – Oakwood Scotland Solicitors
WHAT TO DO NEXT
Get in touch today for a no-obligation consultation. Choose one of the methods on this page, or call us on 0141 406 3324 to find out how we can help you with your enquiry.
