Disabled woman who spent hours on A&E chair died due to neglect

A coroner has ruled that a disabled woman who spent 39 hours on a chair in a busy A&E waiting for a hospital bed died due to neglect.

Marina Young, 46, was suffering from an asthma attack when she was taken to the Royal Preston Hospital, in Lancashire.

Doctors quickly realised she would need to be admitted, but the hospital was full, with more than 50 people waiting in A&E for a bed on a ward.

Although Marina was seen by several junior doctors and nurses, staff underestimated the severity of her condition, failed to give her specialist drugs or refer her to specialist critical care or respiratory medics.

She spent two nights in a chair and, around 10am on the second morning was found collapsed, still fully clothed and wearing her shoes, and soaked in her own urine.

Marina went into cardiac arrest and staff tried to resuscitate her. But when her sister, Michelle Young, 47, arrived a short time later to drop off some belongings, she was given the devastating news that Marina had passed away.

Today Dr James Adeley, senior coroner for Lancashire, ruled there had been gross failures in providing the appropriate assessment and medical care to Marina, and in escalating her treatment to the intensive care unit by hospital staff.

Read More

EXCLUSIVE
Woman, 46, with severe asthma died in horrific circumstances after waiting 39 HOURS in A&E

He concluded her death was caused by neglect, and also issued a prevention of future deaths report, ordering the hospital to make changes to stop similar deaths occurring in the future.

Today Michelle, a retired hospital ward sister, said ‘justice had been done.’

‘All we have ever wanted is to protect other patients and even saving one life would make the pain we’ve been through worthwhile,’ she said. ‘That’s what Marina and my dad would have wanted and it brings me closure to know that has been achieved.

‘Marina’s voice has been heard and it has been recognised that her life did matter.’

An internal investigation by the hospital found that, although Marina had an underlying lung condition and was having a very severe asthma attack, she would not have suffered a cardiac arrest if she had received more timely treatment and been referred to senior doctors sooner.

Marina was diagnosed with spina bifida at birth and was the first baby in the UK to undergo a bladder transplant.

Despite her problems she managed to live independently, could walk short distances and was close to her family.

On the evening of June 20, 2022, Michelle drove Marina to the Royal Preston because she felt wheezy and suspected she was suffering from an asthma attack.

When they arrived, at 7.25pm, Michelle explained her sister’s medical history to nurses and, although she wasn’t allowed to stay because of Covid-19 restrictions, was in regular contact via text messages. The texts reveal her mounting distress, Michelle said.

In one Marina, who had a fear of hospitals because of her experiences as a child, wrote: ‘Scared at night sitting in a chair with a pounding headache’.

The investigation found that Marina was seen by a doctor around 9pm and at just before 11pm on June 20, when a decision was made to admit her to a ward. But A&E was extremely busy that night, with 109 people in the department and around half waiting for a bed.

Although Marina was given antibiotics for a suspected infection, there was a delay in administering nebulisers, a failure to repeat blood gas tests, a delay in her being seen by a senior consultant and a referral to the hospital’s respiratory team the following day was not actioned.

Although further tests in the early hours of June 22 showed no improvement in Marina’s condition and that she was suffering ‘life-threatening asthma,’ her care was also never escalated to the hospital’s critical care team.

At around 9.25am on June 22 Marina, of Ribbleton, Lancashire, was reviewed by a trainee medic, who noted she was ‘speaking in short sentences but was visibly breathless.’

She was seen by a nurse at 9.44am but three minutes later was found collapsed in her chair in cardiac arrest.

Medics tried to resuscitate her but she could not be saved.

Madeleine Langmead, a medical negligence solicitor at law firm JMW, who represented Marina’s family at the two-day inquest, in Preston, this week said: ‘We are grateful to the coroner for his careful investigation into Marina’s care and for reaching this conclusion, which we feel is the only one that could have been made.

‘Marina’s case is likely to have implications for the treatment of other vulnerable patients, particularly those suffering an asthma attack and should improve their patient safety.’

The law firm is evaluating whether any legal claim for compensation can be brought against the hospital.

Michelle previously told the Mail: ‘Marina died in horrific circumstances. It is sickening to think that, as recently as 2022, my sister could be treated with such as lack of compassion by the NHS, which is supposed to care for all people, irrespective of their physical limitations. It appears her disability was not taken into account or recognised by any member of staff at the hospital.

‘The lack of knowledge with regards to spina bifida, and how it affected Marina, left her lacking the care and compassion she required.

‘Her past medical history was fundamental to any care she received, and it should have been at the forefront, with her dignity and basic human needs considered throughout by all staff, but this did not happen.

‘Marina was one of approximately 16 million people in the UK living with a disability, nearly a quarter of the population. It is sickening to think of how many others may have been treated in the same way.’

A spokesman for Lancashire Teaching Hospitals, which runs the Royal Preston, said: ‘The Trust would like to offer its sincere condolences to the family and friends of Marina Young and apologise for the failings identified in our own investigation and the Coroner’s report.

‘We welcome the independent scrutiny of the Coroner and are committed to the further actions and learning identified in the inquest.’

Significant waits in A&E have been linked to excess deaths and increased harm to patients, as their condition can deteriorate before they are admitted or given a bed on a ward.

In 2022, 23,003 people died after spending at least 12 hours in an A&E waiting for care or to be admitted to a bed, according to the Royal College of Emergency Medicine (RCEM), equating to roughly one person every 23 minutes.

Earlier this year Inga Rublite, 39, died after being found unconscious under a coat on the floor of a hospital A&E department, where she had been for eight hours.

Her name had been called three times by staff at the Queen’s Medical centre, in Nottingham, but when she failed to respond, they assumed she had left and discharged her from the system. She had suffered a brain haemorrhage.

Dr Adeley said: ‘Marina died on June 22, 2022 after a 39 hour wait for a hospital bed in the Royal Preston Hospital’s Accident & Emergency Department.

‘Her death, due to asthma, was preventable and was caused by neglect characterised both by a gross failure to provide appropriate assessment and medical care and an inadequate escalation of her management to specialist physicians or ITU.

‘One of the saddest and most upsetting aspects of this case is that when Michelle Young attended the Accident and Emergency department after her sister died, she was still wearing the same clothes and shoes that she was wearing when was admitted to the Accident and Emergency department.’

Dr Adeley also singled out ‘concerning’ assessments completed by two doctors, Dr Thu RaTun and Dr Praktisha Srinivas, who he said he would be writing to the hospital about.