A tragic mistake led to the death of Pat Dawson, a 73-year-old former nurse: staff at the Royal Blackburn Hospital (in the United Kingdom) mistakenly applied a do not resuscitate (DNR) order intended for another patient. The accident immediately triggered an in-depth investigation to ascertain responsibilities in this sad affair. Ms Dawson’s death has highlighted serious shortcomings in hospital procedures.
INSIGHTS
The accident
Pat Dawson, a 73-year-old former nurse, was taken to hospital on September 19 with a suspected intestinal obstruction.
Although she was in good health (she had never sought medical treatment in the last thirty years), her situation rapidly worsened. She collapsed first, a doctor began cardiopulmonary resuscitation, but when her heart stopped beating a second time, the staff decided to consult her medical records. Incorrectly, they read and applied a DNR (do not resuscitate) order, which actually belonged to a 90-year-old man.
The error
The staff realized the mistake they had made too late, when the woman was already dead. With a CT scan it was discovered that the cardiac arrest was caused by pneumonia. The error in checking the records was fatal, together with the failure to verify the patient’s identifying data, such as the national health service number (the equivalent of our tax code) and age: all this played a key role in this tragic story.
The measures
Following the incident, Royal Blackburn Hospital undertook an internal investigation which uncovered a number of issues. The hospital committed to implementing new procedures, which led to limitations on nurse workload and more rigorous review of DNR alerts. Jawad Husain, medical director of the hospital, expressed deep regret for what happened and assured that significant steps have been taken to prevent such a mistake from happening again.
The family’s reaction
Pat Dawson’s son, John, expressed his shock and sorrow at the way the hospital handled the situation. He found it tragically ironic that his mother, who dedicated her entire life to the National Health Service, was the victim of a case of medical malpractice.
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