Warning 'more lives at risk' at hospital trust following beloved nana's death

Peggy with her late husband Jim
Peggy with her late husband Jim -Credit:Family photo

A coroner has warned that more lives could be at risk following repeated failings in the care of a woman who died in hospital.

Margaret Clement, known as Peggy, suffered a massive gastrointestinal bleed while a patient at Pendle Community Hospital. In the days leading up to her death, on June 15 in 2022, nurses had failed to alert doctors to Peggy's deteriorating condition.

An inquest into Peggy's death, which was held this week at Preston Coroner's Court, heard of several failings within East Lancashire Hospitals NHS Foundation Trust. These included inaccurate nursing records, the failure to seek medical assistance for Peggy and a lack of learning from the incident.


Area Coroner Chris Long also highlighted that the evidence suggested that "patients are not priorities" and that doctors didn't review tasks. The coroner is now set to issue a Prevention of Future Deaths report which will require the hospital trust to respond within 56 days.

The coroner told the trust's head of nursing, Nicola Robinson, that he was concerned that despite being two years since 92-year-old Peggy, from Burnley, died, sufficient steps have not been taken to change and improve processes.

Mr Long listed his concerns as: Nursing records were inaccurate, medications, patient reviews, evidence heard patients are not priorities, doctors didn’t review tasks, nurses failed to request medical review, nurses failed to seek medical assistance and that inadequate measures have been taken to learn from Peggy's death.

Mr Long will send the report to the chief executive of East Lancashire Hospitals NHS Trust who will have 56 days to reply and detail how the risks will be rectified.

The two-day inquest heard from whistle-blower Dr Fozia Shah who said she had been reporting her concerns about Pendle Community Hospital for three years before Peggy's death.

Dr Shah said that nurses had failed to alert doctors to signs of Peggy's deterioration. "There is an expectation that... it needs escalating," the doctor said. "Nobody said anything so I was completely unaware."

Dr Shah, who worked at Reedyford from 2019 to 2023, also revealed that she had been reporting her concerns about under-staffing for three years before Peggy's death.

Peggy with her grandchildren and great-grandchildren
Peggy with her grandchildren and great-grandchildren -Credit:Family photo

When she was asked when she started flagging up issues to her superiors the doctor said: "Ever since I worked there. My concerns have been regarding medical staffing.

"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'."

Dr Shah's concerns related to the lack of senior medics at Reedyford. She said that junior doctors were expected to cover the two wards which had no doctors out of hours or at weekends.

"I escalated it because due to the under-staffing things were getting missed," Dr Shah added. "If [Peggy's deterioration] had been escalated we would have done more tests.

"I am so very sorry for the loss of Peggy but all we can do in cases like this is to make sure we do better next time so no other families have to go through the same distress."

At the end of the inquest the coroner returned a narrative conclusion and 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."