West Suffolk Hospital in Bury St Edmunds failed to ‘deliver basic care’ to former Newmarket teacher

A coroner has criticised a hospital for failing to provide basic care to a former Newmarket teacher who subsequently died on its cardiac ward of heart failure.

Seventy-four-year-old Alan Wright, who had also been a stalwart of the Newmarket Twinning Association and Chippenham Cricket Club, died on August 2, 2022, four days after he was admitted to West Suffolk Hospital.

Concluding the inquest into his death on Friday, Suffolk area coroner Darren Stewart said on four occasions despite signs visible to nursing staff at the Bury St Edmunds hospital that Mr Wright’s condition was deteriorating it was not escalated and he was not seen by a clinician.

“I find this was a failure to deliver basic care to a person in need in circumstances where hospital staff knew, or should have known, of Mr Wright’s condition,” said Mr Stewart. “Such a failure was a gross or really serious failure.”

He added: “Each of these occasions constituted a missed opportunity to further identify that Mr Wright was in heart failure. The fact that this occurred in a cardiac ward raises significant concerns to my mind about the approach staff have in relation to the application of News scores (National Early Warning Score).”

Mr Stewart said concerns raised by Mr Wright’s daughter, Helen Waite, on August 1, the day before he died, including that she thought her father was dying, had not been taken into account.

“The effect of the failure meant Mr Wright’s family left the hospital without a clear indication of the serious nature of his condition and the likelihood of a poor outcome for him,” said Mr Stewart.

“They were therefore denied the opportunity to be with him during his final hours and afforded the opportunity to say goodbye to him.”

Dr Khalid Khan, an independent expert witness in cardiology, who gave evidence at the inquest, said there had been a missed opportunity to diagnose Mr Wright’s heart failure during the afternoon of August 1. Had it been he said he would have been placed on a cardiac monitor to identify any further deterioration and might also have been moved to the intensive care unit.

However, Dr Khan said even if Mr Wright’s condition had been correctly diagnosed on August 1 he was not confident he would have survived.

Mr Stewart said he had grave concerns that when Mr Wright’s condition had been escalated in the early hours of August 2 there was no evidence he had been seen by a doctor.

“If it was the case that the escalation did not result in a clinician attending it raises very significant concerns about the efficacy of the escalation system in place on the ward,” he said.

During the hearing, Mrs Waite had read a statement in which she outlined how special her father had been to his family and the wider community, in particular the village of Chippenham where he lived, had been a parish councillor and had for 20 years played for and been an integral part of the village cricket club particularly its youth development, which will now have a programme bearing his name.

“We are devastated by his loss but what makes it harder is the lack of care he received on the cardiology ward, the lack of interest they took in him and their complete lack of empathy after his death, finding it amusing that he had died and that they had had to perform CPR,” she said.

“He wasn’t just a patient they should have treated with respect, he was a much loved father, grandfather, brother, friend, father-in-law, cousin and the heart of a community.

“They could have prevented his death or, at the very least, ensured he didn’t die in agony.”

She said: “The care he received on the A&E ward, and then the acute ward, was very different to the care on the cardiology ward. He wasn’t eating, hardly drinking, he could really hold a proper conversation, his blood pressure was low and he was in so much pain. They just didn’t seem to care.”

After the inquest conclusion, during which the coroner recorded a verdict that Mr Wright had died of natural causes, Mrs Waite said she still believed there had been numerous opportunities to treat her father and potentially save his life.

She said in her opinion these opportunities had been missed and her concerns that her father was seriously unwell and was dying had been dismissed.

“The amber NEWS scores, which should have been escalated to a doctor, and on a critical level, were ignored at least four times.

“As a result my dad spent 12 hours on his own, in pain, dying.

“He should have been in intensive care on a heart monitor. Instead he was alone, unable to sleep, sitting in a chair, having hallucinations and in pain.

“We will never know for sure if he would have survived but we also don’t know that he wouldn’t.

“The coroner has said there were repeated missed opportunities and listed five failings he intended to list in a Prevention of Future Deaths report.”

And she added: “My dad helped people all his life.

“His legacy has to be that he continues to do that so if one person speaks up for themselves, for someone they love, and trusts their instincts because of this it might stop these failings happening to anyone else.”

Sue Wilkinson, chief nurse of the West Suffolk NHS Foundation Trust, said: “We offer our sincere and heartfelt apologies to the family of Mr Alan Wright and for the impact our failures have had on them.

“Every patient deserves the highest quality and safest care, and we know we should and could have done better.

“Since Mr Wright died, we have made significant changes to ensure we learn from and improve how we care for our patients.

“This includes observations, escalating signs of deterioration, strengthening our patient safety initiatives, and ensuring clearer communication with the families and loved ones of those in our care.”