A grandmother who went to hospital on three separate occasions with a broken arm died because staff did not know she was there.
Patricia Fowler, 75, was left waiting on a cardiac ward and wasn’t seen by a consultant on three different days because of a mix-up over patients’ names.
An inquest heard her name had been on a list sent to consultants, but because she had the same first name as another patient she was ignored.
Staff at Blackpool Victoria Hospital, Lancashire, failed to recognise that Mrs Fowler was a different patient with a different surname.
By the time the mistake had been noticed, Mrs Fowler had developed pneumonia and sepsis, which led to her death.
“Going into hospital killed my mother,” said Scott Fowler, the youngest of Mrs Fowler’s four children.
“The grief we all feel has devastated us and the personal guilt I feel is immense.”
Mrs Fowler, a retired widow and grandmother of five from Fleetwood, Lancashire, went to A&E on January 4 this year after falling and was admitted to hospital.
She was discharged two days later with plans to attend a fracture clinic the following week, but was readmitted on January 9 after being referred back by her GP.
After being admitted to the Acute Medical Unit, she was transferred to a cardiac ward shortly before 3am on January 10.
She was seen two days later in the fracture clinic, but not reviewed by a consultant until January 13, when she was seen following “an acute deterioration”, the hospital’s serious incident report (SUI) said.
Mrs Fowler was then transferred to the Intensive Care Unit (ITU) with severe sepsis and placed on a ventilator.
Mrs Fowler’s death prompted an internal investigation at the hospital and an inquest.
In a statement to the coroner, Angela Russell, medical secretary in the Care of the Elderly department, said patients’ names were written on a white board in the bed managers’ office, before the patients were shared among the consultants.
At the end of November, the list started to be sent by email and the list contained names, but no hospital numbers, NHS numbers, or dates of birth.
Ms Russell added: “In this particular case there had been a patient with the same forename, which appeared in exactly the same place on the emailed list.”
Anaesthetist Dr Matthew Bowker told a subsequent investigation he expressed concerns after Mrs Fowler wasn’t “reviewed by a member of her medical team” from the time she was moved onto the cardiac ward until three days later.
Mrs Fowler was assigned to the Care of the Elderly team but was not seen on January 10, 11, or 12, before several calls were made to doctors on the 13th, which meant she was seen at 2.50pm, 8pm, and 10pm.
She died two days later on January 15, with a post-mortem examination ruling the cause of death as sepsis and pneumonia, with her broken arm a contributing factor.
Mr Fowler, who lost his dad, Brian Fowler, in 2006, said: “Quite simply, my mum died because she went into that hospital.
“If she had been seen, or a nurse had noticed she hadn’t been seen, she would still be here now.”
In a statement, the trust said: “Blackpool Teaching Hospitals NHS Foundation Trust has admitted liability in this matter and has passed on its sincere condolences and apologies to Mrs Fowler’s family.
“A full investigation was carried out into the circumstances of Mrs Fowler’s hospital journey and a number of changes have been implemented as a result of the findings of that investigation.”
However, Mr Fowler said: “We feel as though there is no accountability. They’ve admitted liability but that’s not enough.
“Something needs to change and we need to see more than just an apology.”