Peter Stephens, aged 64, from Blackburn, died at the Leeds General Infirmary on 7th September 2017.
The Inquest was heard at Wakefield Coroner’s Court by HM Area Coroner, Jonathan Leach. After hearing evidence from a number of consultants, nursing and leadership staff the Coroner concluded that Peter’s death had been contributed to by gross failings on the part of nursing staff in charge of his care.
Having been admitted to hospital following a heart attack on 25th August 2017, Peter suffered a further cardiac arrest on the morning of the 30th August 2017 whilst awaiting a procedure to insert an implantable cardiac defibrillator. The decision was made to put Peter on cardiac telemetry monitoring in order to give medical staff advance warning of any further heart problems.
On the evening of 4th September 2017 the battery on the telemetry unit began to fail. Despite at least 40 minutes before the battery fully depleted, an audible warning was made at the nurses station, this alarm was silenced by nursing staff without the battery being replaced. The evidence revealed that this alarm would have resounded every three minutes and yet, inexplicably, the battery was never changed. The Coroner found that the alarm would have been cancelled up to ten times without the obvious remedial action being taken.
Unfortunately, those gross errors were further compounded by the failure of the nursing staff on the night shift to observe the telemetry readings at the nurses’ station at any time. Doing so would have immediately revealed that the battery had died.
No less than twelve hours after the warning alarm had first sounded, Peter suffered a further cardiac arrest at approximately 6.20 am on the 5th September 2017. The absence of the advance warning that would have been provided by the telemetry system resulted in a delay in medical treatment being provided.
As a result, Peter suffered a catastrophic brain injury and sadly died on 7th September 2017.
Peter’s son David, on behalf of the family said;
We as a family are devastated at the loss of my father whose death in our view should have been prevented if the basic healthcare to which he was entitled had been provided. We would not want any other family to have the same experience and have been left appalled at the multiple failings that have come to light.
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