'Repeated failures' at hospital slammed after beloved nana bled to death

Peggy with her grandchildren Rebecca and Tony, and their children Paris, Peaches and Lewis
Peggy with her grandchildren Rebecca and Tony, and their children Paris, Peaches and Lewis -Credit:Family photo

A coroner has called for improvements at a community hospital after a much-loved nana died when nurses failed to alert doctors to her deteriorating condition.

Margaret Clement - known as Peggy - died at the Royal Blackburn Hospital in June 2022. The mum-of-three had been admitted to hospital after breaking her hip around three weeks earlier.

Following an operation to repair her fractured hip, Peggy, from Burnley, was transferred to Pendle Community Hospital's Reedyford ward in Nelson but her family began to raise concerns after noticing she was becoming progressively unwell.


Despite Peggy's deteriorating condition nurses failed to alert doctors and, on June 14, she was taken by ambulance back to the Royal Blackburn Hospital where medics discovered she was suffering a gastrointestinal bleed. The following morning Peggy was taken for an endoscopy to locate the source of the bleeding but the 92-year-old then suffered a cardiac arrest and died.

At an inquest held this week at Preston Coroner's Court Nicola Robinson, the head of nursing at East Lancashire Hospitals NHS Trust, conceded that it had been a "very serious error" when nurses had failed to alert doctors when Peggy became unwell while at Reedyford.

Dr Fozia Shah, who was a doctor at Reedyford at the time of Peggy's death, was visibly shocked as she was told that nurses had not contacted a doctor when Peggy's condition deteriorated. Dr Shah revealed that she had been reporting her concerns about under-staffing at Reedyford for three years before Peggy's death.

She said: "I escalated it to my seniors because I found myself in the situation where I had no choice but to raise my concerns about the vulnerability of the ward but I got no answers. I got so frustrated that I went directly to the medical director Jawad Husain. I said 'it's a huge risk'."

Head of nursing Ms Robinson admitted to the coroner that she "can't promise" that what happened to Peggy won't happen again. However, she said that training is ongoing, and told the coroner that she believes that Reedyford has "turned a corner".

Area Coroner Chris Long said: "What I’ve found is a number of nursing and clinical failures in her care. Her death was not as it should have been."

However, despite the failings, the coroner found that even if Peggy's care had been better it would not have affected the outcome. He concluded that the delays in treating Peggy did not contribute to her death.

Returning a narrative conclusion, the coroner said: "Margaret Clement died on 15 June 2022 at Royal Blackburn Hospital, Blackburn. Following a fall, Mrs Clement was admitted to hospital where a fractured neck of femur was diagnosed and operated upon on 23 May 2022.

"Mrs Clement was prescribed anticoagulation following the operation to reduce the risk of clotting. She was discharged to Pendle Community hospital for rehabilitation on 10 June 2022.

"She had suspected melaena in the evening on 12 June 2022. She then developed significant rectal bleeding in the morning of 14 June 2022 and was admitted to Royal Blackburn Hospital following vomiting blood later in the evening.

"An upper gastrointestinal bleed was then diagnosed which led to a cerebrovascular accident from which she did not recover."

Peggy's granddaughter Rebecca described her as "funny and ferocious". She said: "The pain and distress my gran felt at this time is beyond immeasurable, but the undignified ending is something she would have been furious about.

"People never really understand why dignity in death is so important, until they witness someone have a highly undignified death.

"Two years later, when I have to walk those halls of Blackburn hospital, especially passing the endoscopy unit, I will often be found in tears, struggling to move and frozen to the spot in fear or sadness.

"Most people you pass in a hospital will be going through something, and we just see them, thinking they are carrying about their day. Now, I look for people who may be really struggling.

"I’ll never forget the couple who approached me, as Gran had died and we were leaving the hospital. I was doubled over in tears, waiting for my mum to validate parking.

"I didn't think, when I entered the hospital to make sure Gran was ok after endoscopy that I would be leaving without her… but complete strangers came to console me. It’s the small things when you feel like you’ve lost everything."