East Kent Hospitals Trust 'truly sorry' for failings in care of grandmother who died at William Harvey Hospital in Ashford
Published: 05:00, 11 April 2023
Updated: 13:08, 11 April 2023
Doctors involved in the care of a much-loved grandmother made "indefensible” decisions about her treatment in the days before her death, a damning report claims.
Diabetic Hazel Turner, 86, was not expected to die when she was admitted to the William Harvey Hospital in Ashford with pneumonia and breathing issues, and was even given an estimated discharge date.
But several days later she was made "nil by mouth" by doctors, withholding all oral nutrition and hydration, without her family being told.
She died on September 29, 2015, having had no fluids for 48 hours and just one meal in seven days, which had been fed to her by her son, who was unaware of the doctors’ orders.
She was officially ruled to have died from pneumonia, but a retired consultant giving expert opinion during a police investigation suggested dehydration could have been the “principal cause” of her death, and at least a contributory factor.
Now, the case has been examined in a damning report shining a spotlight on failures in end-of-life care.
The study, called When End of Life Care Goes Wrong, was commissioned by the Lords and Commons Family and Child Protection Group “against a background of mounting anger and complaint on the part of bereaved relatives”.
Some complainants claimed their loved ones had been “deliberately killed by inappropriate withdrawal of food and hydration”.
In the report, the East Kent Hospitals Trust, which runs the William Harvey, is criticised in Mrs Turner’s case, alongside Kent Police, the General Medical Council (GMC) and the Care Quality Commision (CQC).
Mrs Turner’s death is described as “avoidable” by barrister and medical law specialist James Bogle, while retired consultant neurologist Professor Patrick Pullicino is damning in his judgement of the treatment she received.
Asked to give independent expert opinion to Kent Police’s serious case review team, Prof Pullicino wrote: “Mrs Turner was dehydrated secondary to inadequate fluids being prescribed and/or given to her.
“In a person like her, with co-existing medical illness, this prolonged dehydration would certainly have contributed to her death, and given that she had no fluids at all for the last 48 hours of her life, it could even have been the principal cause of death.”
Mrs Turner’s devastated family say despite her age, they were "not expecting her to die" when she went into hospital.
Her daughter, Catherine Ashenfelter, says they were not consulted on changes to her mother’s care, and felt that doctors had set her on a ‘pathway’ to death.
"Mum was admitted with breathing problems and suspected pneumonia but she wasn’t diagnosed as dying,” she said.
"A nurse even wrote in her notes that she had no swallowing problem and was talking oral tablets very well.
"She had a procedure to drain one of her lungs because she had some fluid in it and that was successful.
"But they made her nil by mouth for a week without doing a swallow test, when she was diabetic. I only found out three months after her death when I was given her medical notes. I was frozen with shock.
"In the legal overview, the barrister does use the words 'avoidable death' and I support him with his judgement."
Mrs Turner needed to be hoisted as she had suffered a broken leg that, although healed, she was unable to put weight on.
Mrs Ashenfelter says in the report: “A registrar showed prejudice towards Hazel’s disability, saying 'it’s not a nice life to be hoisted', before placing Hazel on end of life.
“Hazel had an IV drip, yet blood tests revealed she was dehydrated. Instead of increasing her fluid, it was decreased.”
The year after Mrs Turner’s death, the-then chief executive of East Kent Hospitals, Matthew Kershaw, wrote to Mrs Ashenfelter offering a number of apologies, mostly concerning inadequate communication about her mother’s care.
He said that certain medical decisions were taken because Mrs Turner was deemed to be at the end of her life, but conceded that a consultant involved in her treatment would not, in hindsight, have made the nil by mouth order.
In 2018, the Parliamentary and Health Service Ombudsman found there were two failings in Mrs Turner's care.
The first was that "medicines reconciliation [was] not carried out within 24 hours of admission as per the National Institute for Health and Care Excellence (NICE) guidance 2015" and the second was a lack of communication regarding whether Mrs Turner was in fact nil by mouth.
Mrs Ashenfelter raised her mother’s death with Kent Police in 2019, but the force said the case "did not meet the evidential test for any criminal prosecution" and no further action was taken. A further serious case review reached the same conclusion.
Two years later the General Medical Council found no malpractice by doctors.
In the report, Professor Sam Ahmedzai, who has more than 30 years experience in cancer and palliative medicine, expressed concerns over the GMC's "apparent failure to find evidence of malpractice by doctors in spite of Ombudsman findings and even though the hospital trust had admitted fundamental errors".
He says that Mrs Turner was “failed” by the “routine safeguards that should protect vulnerable older people”.
"In my opinion, this is disputable and many of the medical decisions taken by the doctors would be indefensible in the eyes of their peers...”
He explains: "These were the hospital trust admitted to many mistakes, including that she should never have been placed on the [nil by mouth] order.
"Kent Police initiated a serious case review and then failed to act on the findings of an independent expert witness, Professor Pullicino, and neither did they refer the case to the coroner, which in my understanding could be seen as a serious breach of their duty to the safety of the public."
Prof Ahmedzai adds that from the “numerous apologies for deficiencies” in the Trust’s letter, it is clear the hospital “fell short in many ways” of meeting national guidelines, despite its chief executive claiming this to be the case.
Prof Ahmedzai added: “In my opinion, this is disputable and many of the medical decisions taken by the doctors would be indefensible in the eyes of their peers.”
He also criticises a "lack of action so far from CQC".
Kent Police says an investigation of all available evidence was carried out regarding Mrs Turner's death.
A spokesman added: "Kent Police was contacted in April 2019 concerning the death of a woman in her 80s at the William Harvey Hospital in Ashford in September 2015.
"An investigation of all available evidence was carried out, including the findings of prior reviews by the hospital and the Parliamentary and Health Service Ombudsman.
"Following a thorough investigation, the case did not meet the evidential test for any criminal prosecution and no further action was taken.
"A review of the case carried out in November 2019 found no reason to reopen the investigation and the senior investigating officer updated the woman’s daughter in person.
"Kent Police offers its condolences to the family."
The GMC was unable to provide a comment about Mrs Turner's case because it is only able to disclose information that is publicly available about individual doctors on its website.
A spokesman said: "We carefully consider all complaints raised with us, and thoroughly examine all relevant information before making a decision on the complaint.
"We investigate when concerns are raised about a doctor's ability to practise safely or threaten public confidence in the profession."
Executive editor of the report The Rev Lynda Rose says the work of the parliamentary group showed "all too clearly that misdiagnoses and mis-assessments as to quality of life and proximity to dying are disturbingly common".
Responding to its findings, Sarah Shingler, chief nursing and midwifery officer at East Kent Hospital Trust, said: “I am truly sorry for Ms Turner’s family’s loss and for the failings in the care she received in 2015.
"The Trust fully accepted the findings of the Parliamentary Health and Social Care Ombudsman in 2017 and implemented all of its recommendations, including ensuring staff discuss the nutritional status of all inpatients at handover and a refocused pharmacy service to reduce medication errors.
“We have worked hard to improve end-of-life care, including training staff in communicating with patients and their families at the end of life.
"We now have a palliative care team of nurses and medical consultants who have specialist training and experience in place.”
But now, Mrs Ashenfelter hopes to use her mother's care as an example to others.
"I want to get across that end-of-life is not a natural death, it’s a pre-planned pathway," she said.
“I don’t feel my mother’s time was up.”
"She was very friendly and sociable, listening to people's problems, giving free advice and words of wisdom..."
Mrs Turner, a widow since her beloved husband Alan died in 1999, had lived in Brook, near Ashford, for more than 50 years.
“She was a truly kind lady, always thinking and doing things for others, getting involved with community and church work," Mrs Ashenfelter said.
"She was very friendly and sociable, listening to people's problems, giving free advice and words of wisdom.
“She worshipped at St Mary's Church in Brook, where she and my father are buried together.
“She also liked to have a laugh; was a positive person and fought for a smile even during times of suffering. She was a special lady and I still miss her very much.”
The CQC was approached for comment.
More by this authorLiane Castle