A PATIENT was "left to bleed to death" on a hospital ward after nurses did not carry out observations on her for 16 hours.
Susan Wilson, 58, of Larkhill Village, Clifton, was recovering on Ward E15 at the Queen's Medical Centre after having her gallbladder removed last October.
Staff nurse Neil Bailey only realised he had not carried out four-hourly observations on her at the end of his night shift, when Mrs Wilson may well have been dead for several hours.
He told an inquest into her death yesterday he was too busy on his shift to check observations on Mrs Wilson and admitted her requirements were "overlooked".
"At no point did I make a conscious decision not to attend to Susan," he said.
He told Deputy Coroner Heidi Connor that he felt "somewhat overwhelmed that night" and at times found it "very difficult" to deliver care in an organised and orderly manner.
"When I handed over my patients (at the end of my shift), I became aware I had entirely overlooked Susan's needs and requirements and went to check her and it was at that time I discovered her to have no signs of life," he said.
Mrs Wilson had decided to go ahead with the operation to deal with a painful gallbladder and was aware of the risks because of an existing heart problem.
After the op, she spent time on a high-dependency unit before she was moved to Ward E18, where nursing observations should have been carried out.
The coroner recorded a narrative verdict and deemed the cause of Mrs Wilson's death was a heart attack caused by bleeding she suffered after the operation.
However, she said there were "too many unknowns" to say whether her death would have been avoided if observations had been carried out.
"To miss or delay one observation is one thing but to have no observations in an entire 12-hour shift and no notes at all is nothing short of shocking," Said Mrs Connor. "It's clear he (Mr Bailey) felt overwhelmed and I have some sympathy in that respect. Staff Nurse Bailey failed to provide the medical attention Susan needed."
The court had heard about staffing in the ward and concerns that Mr Bailey, who had been caring for ten of the 28 patients, had previously raised.
The coroner said staffing was a national crisis and not unique to this geographical area, adding: "It goes without saying this is something the trust needs to prioritise to avoid tragedies like the one we have heard about today."
After the hearing, Paul Sankey, clinical negligence lawyer with London law firm Slater and Gordon, said: "Susan Wilson's tragic death was wholly avoidable. She was left to bleed to death on a ward and no one noticed.
"After 16 hours on a ward, none of her four-hourly observations had been done. Had nurses checked her vital signs, they would have realised that she was deteriorating, infused blood and returned her to the high-dependency unit.
"She would not have died. The nursing care she received was inadequate and there were too few staff on the ward.
"The Care Quality Commission has raised concerns about staffing levels at Queen's Medical Centre and the trust running the hospital need to take note."
Jenny Leggott, director of nursing and midwifery for Nottingham University Hospitals Trust, said: "We extend our condolences and reiterate our apology to the family for failing our basic duties of care and letting Mrs Wilson and them down so badly.
"The absence of regular clinical observations and checks on Mrs Wilson overnight when she passed away meant her deteriorating condition regrettably went unnoticed.
"We have learnt from this tragic case and made changes to improve safety and outcomes for our future patients.
"We are closely monitoring the implementation of all of the recommendations at the highest level."
Ms Leggott said the trust had implemented a series of improvements, including better communication and a training programme for junior doctors and nurses to help them recognise the deterioration of patients and alert senior colleagues.
