SERIOUS flaws in the care of five patients at a special hospital unit contributed to their deaths, The Argus has learnt.

Such is the concern surrounding the Royal Sussex County Hospital’s Acute Medical Unit (AMU) that the Brighton coroner has issued five emergency notices within the last 14 months ordering it to take action to prevent other deaths.

In the most recent case 89-year-old Evelyn Kennedy was so badly neglected in the unit that coroner Veronica Hamilton-Deeley concluded it had “probably accelerated her death by a short time”.

She recorded Mrs Kennedy’s treatment was “chaotic” and “not fit for purpose” and issued a Regulation 28 “prevention of future death” notice to the hospital.

It was the fifth such order over deaths within the last two years, the previous one coming just one month before the pensioner died in the unit.

Concerns have also been raised internally about the hospital’s failure to respond adequately to concerns about the ward, which takes patients from Accident and Emergency (A&E) who need to be assessed further.

They are meant to stay there for only 48 hours but it is frequently longer. The patients are mostly elderly.

The news comes after an unannounced visit by the local health watchdog Healthwatch in January.

Staff told inspectors that about one-third of patients were placed appropriately at the AMU, with others unable to be transferred out of the unit due to a lack of available beds.

The hospital says significant improvements have been made to the ward, including reducing the ratio of patients to staff and doing regular safety reviews.

Mrs Kennedy was admitted to the AMU after a fall in October 2014 but was badly neglected during her five-day stay there. When she was transferred to the Bristol Ward, she was suffering from dehydration, was soiled and had sores on her mouth. Nurses there raised the alarm.

In May 2014, Linda Rignall died from an undiagnosed blockage in the artery transporting blood to the lungs.

The coroner said the failure to refer her for a medical opinion after observations meant the window of opportunity to treat her was lost.

In August 2013, 94-year-old Herta Woods was admitted to A&E after a fall and was taken to the AMU ward, where she died about four hours later.

She had been overloaded with fluid from an intravenous drip.

The coroner criticised both A&E and the AMU, raising concerns over the “apparent abandonment of this lady in AMU”.

Those are among the failings catalogued in the reports issued by the coroner, unearthed by The Argus.

Chief executive Matthew Kershaw said yesterday that “failings have undeniably occurred in the past but I would not want these incidents to cause unnecessary fear or anxiety in those patients, or their families, who may be admitted to the unit in the future”.

He added: “The team who work in our AMU are caring, committed and continue to work very hard to make improvements to the quality and safety of the care they provide.”

Mr Kershaw acknowledged “unacceptable failings” in the care that Mrs Kennedy received while she was in the AMU in October last year, adding: “We have apologised unreservedly for these, and offered our condolences to her family for their loss.”

He added: “We also acknowledge that on a number of other occasions before this, the standard of care in our Acute Medical Unit fell below the high levels that our staff strive to deliver and our patients and their families have a right to expect.

“We have made significant improvements to the unit’s workforce, environment, equipment, patient flow, teamwork and communication, and these are having a positive impact on the care being provided and the experience of the patients on the unit today.

“These improvements include employing additional staff, including more nurses and a matron to support safety and quality in the unit, undertaking regular safety and quality reviews of the unit and forming a dementia working group to make the unit dementia-friendly.

“We have also removed nine beds from the Acute Medical Unit to improve the ratio of staff to patients in this very busy and pressurised environment.”

The Argus: Evelyn Kennedy

NARRATIVE

MUCH-loved great grandmother Evelyn Kennedy was admitted to the acute medical unit after falling over and hurting herself. By the time she was transferred to the Bristol Ward five days later, she was soiled, dehydrated and had sores stuck to her mouth.

She was also missing the wristbands supposed to be tagged onto patients to show their name, date of birth and other medical needs, so staff can act accordingly.

The 89-year-old had been neglected so badly that nurses in the next ward, Bristol Ward, raised the alarm to their superiors about her care.

When her family saw her there she screamed at them, “Help me, don’t leave me,” her granddaughter, Emily Kennedy, told The Argus.

The 30-year-old, of Hove, added: “It was awful and it was because she was scared of being left alone again. So the last ten days of her life she was in a lot of distress. It was sad and horrible.”

The family feels “guilty”, Ms Kennedy added, because they were unable to visit Mrs Kennedy during those five days in the acute medical unit.

Mrs Kennedy’s daughter has cancer and was therefore told not to visit due to the risk of infection, while Ms Kennedy was busy looking after her toddler after her partner broke his foot.

They found out about what the extent of neglect on AMU when a representative from the hospital came around to let them know and assured them they were “taking it seriously”.

“She had been in and out of hospital and we have always been there straight away by her side so we could help,” Ms Kennedy said. “But we feel awful as a family and guilty because those five days were the only times in my whole life that we were not able to be with her.”

One month before Mrs Kennedy’s death in October 2014, the hospital had been sent a letter by the Brighton and Hove coroner asking them to take action following the death of another AMU patient Linda Rignall.

The 55-year-old, from Peacehaven, died in May 2014 after being admitted to the unit from an undiagnosed blockage in the artery that carries blood to the lungs.

The coroner said she had not been referred for assessment despite observations suggesting she should have been, adding that “this failure to refer her resulted in the only window of opportunity available to treat her being lost”.

Coroner Veronica Hamilton-Deeley said what happened made her concerned “as to AMU’s Fitness for Purpose at the current time.” She used that phrase again in regards to Mrs Kennedy’s time at the AMU.

Before this, four months before Mrs Kennedy’s admission to AMU, another patient had died, from atypical pneumonia, in circumstances that prompted the coroner to tell the hospital to take action, saying poor care meant chances to diagnose were possibly lost.

Earlier in 2014, in February the coroner had also written to the hospital asking them to take action after the death of another patient 94-year-old Herta Woods.

Mrs Woods, from Horsham, had been admitted to the acute medical unit from the accident and emergency department following a fall down the stairs at home in Horsham.

She was admitted to AMU at 5pm on August 7 2013 and eventually arrived there at 9.30pm. She died after midnight on August having been overloaded with fluids.

The coroner raised concerns about the “apparent abandonment of this lady in AMU” and noted that the document sheets were completely blank.

She said Mrs Woods was very likely near the end of her life, but “from the evidence I have heard, would not have died when she did had she been given appropriate care and treatment.”

Just the previous day, Mrs Hamilton-Deeley had written to the hospital telling it to take action about another patient, Stephen Palmer, who had died in July the year before.

Following his inquest, she expressed her concern about delays in treating him in accident and emergency, and an inappropriate transfer to the acute medical unit.

She said an inadequate ward round note made by hurried staff meant nursing staff in the acute medical unit were unable to look after their patient properly.

This January, representatives from Healthwatch Brighton and Hove visited the Acute Medical Unit along with other wards as part of an unannounced inspection.

Staff told them that 63 % of patients were placed there inappropriately, adding that in reality the ward was being used for overspill for older people’s wards and A&E. They said the longest stay was five weeks.

They described “very positive examples of good care” but also some examples of poorer communication, noting that most patients and their visitors felt happy with the service they received in Royal Sussex County’s older people’s wards.

Given the number of calls to action that had gone before, Mrs Kennedy’s family expressed doubts about what the coroner’s intervention would achieve.

Her granddaughter said: “She did issue a Regulation 28 notice but that is what she had done with previous inquests.

“So the coroner is very good, she has been very thorough, but she has asked that before and there have still have not been changes.

“The manager of the acute medical unit came to the last day of the inquest and was called up as a witness.

“He said he had raised concerns about the unit and up to a higher level and just about the running of it and how he did not find it acceptable.

“He said that they keep making action plans but nothing has really happened.”

“Obviously we would like to see a change – we do not want to see this happen to other families it was so hard dealing with her death. We were so close, and then finding out that. “We really hope that can be prevented for anybody else, but there needs to be a lot of changes.”

The five cases

1. In July 2013 Stephen Palmer, from Brighton, was admitted to A&E with acute abdomen.

He was “inappropriately” transferred to the acute medical unit when he should have stayed in A&E or gone to a surgical unit, the coroner said: “There was a failure to prepare him for surgery and a failure of the CT scanning service at the hospital meant his condition went undiagnosed”.

2. On August 7, 2013, Herta Woods, 94, from Horsham, was admitted to Accident and Emergency, in a trial fibrillation. She was suffering from a condition that leads to the release of muscle fiber contents, harmful to the kidney, into the blood. Her fluid balance charts were not written up correctly and a scoring system used to flag up when critical care is needed was not adhered to.

She was admitted to AMU at 5pm, arriving there at 9.30pm. The coroner said the AMU records were completely blank. She died shortly after midnight on August 8 from fluid overload following administration of intravenous fluid.

3. In May 2014, Linda Rignall, 55, from Peacehaven, was in the acute medical unit when her condition changed. She was not assessed and when she worsened some four hours later there was still no request for a medical review. She died from an undiagnosed pulmonary embolism. The coroner said failure to refer her resulted in the only window of opportunity available to treat her being lost.

4. On June 17, 2014, a woman died from a typical pneumonia. The coroner flagged up poor care and said windows of opportunity to diagnose her were lost.

5. In October 2014, Evelyn Kennedy, 89, from Hove, was admitted to accident and emergency.

Over the next five days she was neglected to the point that nurses in the next ward raised the alarm about her care. She died of hospital-acquired pneumonia on October 29, 2014. The coroner said the care she had received “probably accelerated” her death by a short time.