Decade-long battle for answers after death of woman who inhaled own vomit

Elsie Brooks, who died in King George Hospital

Elsie Brooks, who died in King George Hospital. - Credit: Brooks family

A hospital trust has apologised to the family of a woman who died after inhaling her own vomit on a ward branded "not fit for purpose".

Elsie Brooks, of Lambourne Road, Barking, died from a septic infection at King George Hospital in January 2010 after she was put onto a contingency ward rather than a high-dependency one after an elective hernia repair surgery.

An initial inquest into her death took place at Walthamstow Coroners' Court in November 2014, but a second one was allowed to take place at Southwark Crown Court following a High Court decision.

During the initial inquest, it was reported that the 89-year-old was put onto a contingency ward set up following an outbreak of norovirus following her surgery.

The court heard how there had been no senior nurse in charge of the team, which was made up of agency staff and nurses from other departments.

Mrs Brooks developed blood poisoning while waiting for a consultant to assess her after aspirating the vomit, and despite then being moved to intensive care, she died three weeks later.

The outcome of the second inquest, which concluded on Tuesday, November 16, was welcomed by Mrs Brooks' daughters Janet and Margaret.

In a statement, they said: "The inquest showed that there was a significant delay in providing our mother with potentially life-saving antibiotics to treat her sepsis in January 2010.

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"This has always been a major concern for us and the evidence we heard confirms that these ought to have been given much earlier.

"Importantly to us, the inquest showed that our mother aspirated her own vomit as a result of the lack of nursing care and equipment on the contingency ward, and that this contributed to her fatal chest infection."

Matthew Trainer, chief executive of Barking, Havering and Redbridge University Hospitals NHS Trust, which runs the Goodmayes hospital, offered an apology on behalf of the trust and said changes had been made.

He said: “We would like to apologise again to Mrs Brooks’ family, as the care she received in our hospital was simply not good enough. We accept that the way we managed the complaints process caused unnecessary distress.

“Since Mrs Brooks' death, we have increased staffing levels to care for patients post-surgery; implemented mandatory competency training to ensure medical staff can correctly insert and monitor nasogastric tubes; and we’ve introduced a new system, SafeCare, which monitors patients and can help highlight those who are deteriorating and where additional support may be necessary.”

One of the key findings at the second inquest, which was welcomed by Mrs Brooks' daughters, was around the issue of her consent to the surgery.

As Mrs Brooks' surgery was elective rather than emergency, her pre-operative and post-operative care had to be of the standard expected to justify it going ahead.

The family statement added: "We are relieved that the coroner recognised that our mother, as well as us, would not have consented to the surgery without a high dependency unit bed.

"We have fought 11 years to find out why and how the trust failed our mother. After more than a decade, we finally have a coroner’s conclusion.

"We hope that the trust will continue to learn lessons from these failures and that we have spared other families from the neglect our mother suffered."

Daniel Cooper, the family's solicitor, added: "This result is long-awaited by the family. No family should have to endure the pain of watching their loved one deteriorate in a hospital ward that is simply not fit for purpose.

"We are pleased to learn that the trust have brought in a number of changes since 2009 and hope that this case continues to serve as a reminder on the importance of the placement, planning and communication for vulnerable surgical patients."

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