WORCESTERSHIRE NHS Trust has apologised for failing to care for a woman who died at Redditch’s Alexandra Hospital after alarms alerting staff to her condition went ‘unheeded for some nine minutes’.
Lucy Phelan was taken to hospital on May 13 last year after being found unresponsive at home, having vomited from taking prescribed medications with alcohol.
She lived with Emotionally Unstable Personality Disorder, which led her to occasionally indulge in risk-taking behaviour, and later went into cardiopulmonary arrest.
She was taken by ambulance to the Alex where she was treated for likely aspiration pneumonia, but later that evening vomited again and soon after that went into cardiopulmonary arrest.
Alarms notifying staff at the hospital of her collapse went unheeded for nine minutes. When an emergency was called, doctors were unable to resuscitate her and she was confirmed dead shortly after midnight on May 14.
The coroners report raised concerns about the monitoring equipment used, as it has facility known as ‘latching’.
This meant, if activated, the alarm would continue to be displayed and sounded even after the conditions which generated it had ended.
The inquest heard evidence that ‘alarm fatigue’ was a recognised phenomenon.
And, in a busy environment like a hospital’s Emergency Department, particularly when patient numbers were high, staff found it increasingly difficult to react and respond to the many different types of alarm in use.
David Donald William REID, HM Senior Coroner for Worcestershire has recommended action should be taken to prevent future deaths by reviewing the use of the ‘latching’ facility.
Hayley Flavell, Chief Nursing Officer for Worcestershire Acute Hospitals NHS Trust, said: “I would like to offer my deepest condolences to Lucy’s family and apologise to them unreservedly for the failings in the care she received from us.
“We have carried out a thorough investigation into what went wrong and put a number of immediate actions in place to address the issues identified.
“We will respond to the Coroner fully by the requested date.”
