Coroner says care of dying mum '˜wholly inadequate'

An inquest into the death of Angela Turner, found that a “sub-optimal” assessment into her fatal condition led to her being wrongly discharged from care.

Other news: Litterbug motorists could face fines up to £120It was December 30 when Angela began complaining of an intense pain in her head like a “ball of pressure”.

The 57-year-old single mum, who had hosted Christmas dinner for her family just days before, told her son Skott Martyn that the headache would not go away, even with rest. She was also experiencing pins and needles, pain in her upper limbs and had been sick.

Concerned by her symptoms, Skott followed the well-known advice - to call 111 unless there is a life-threatening emergency - but due to staff sickness was forced to wait for 45 minutes before abandoning his plea for help.

Skott, 39, said that his mum was failed by “every channel of support” available to her after the pair were forced to visit the walk-in-centre at Leigh , where she received the fatal misdiagnosis.

After failing to contact the NHS helpline, Skott tried his mum’s GP surgery, but was told everyone was leaving for New Year.

He then called the out of hours service who advised him that there was a seven-hour wait time at the hospital and that he should go to the walk-in centre.

“They told me not to take my mum to the hospital,” he said. “I think that was the wrong advice. Collectively the NHS failed her.

“The walk-in centre were far too busy to see her, but the receptionist recognised the urgency and after a short wait we went through.

“Mum described her symptoms but the nurse was making her work very hard with her questioning - she later told me she made her feel like a burden.”

Following the triage, Skott described how Angela was told to go and lie-down in another room while the nurse told her colleagues - “this lady has a headache”.

“It was very belittling and very unfair,” he said. “I feel like at what was a vital stage, she was discouraging the approval of mum getting a much-needed brain scan.”

Angela was then forced to wait almost an hour and a half in agony until she was seen again, this time by a nurse practitioner.

Once she had described her symptoms, Angela was given a neurological exam which involved having to follow the practitioner’s finger with her eyes. The exam was performed three times in a row, but the pair were not told what the results were from this.

Skott later learnt that no pain assessment had been carried out, which breaks NHS protocol.

“He seemed very uncertain with his diagnosis,” said her grieving son. “He said ‘you have a migraine love, I get them three times a week, I take paracetamol for mine and still cycle to work’.”

On the advice of the two healthcare professionals who had carried out assessments, Skott took his mum home.

Later she contacted him saying: “I have pain all over, I’m going to try and sleep it off. Love you and thanks for everything.”

The next day Angela was found collapsed and in a coma from which she never woke. She died in Salford Royal Hospital 10 days later on January 10.

“Mum had all the symptoms of a brain haemorrhage,” said Skott. “In hindsight, if I was aware of them, it would have been a 999 call I made.

“These were trained specialists. You would expect them to pick up on things like that.

“Even at the inquest, no one held their hands up. Mistakes were made on paper. Without those, my mum would have lived.

“I am completely broken from this. Mum was 57, that’s no age. One day you’re sitting around the table having Christmas dinner then your mum dies and you are organising skips to throw away the tables and chairs you were sitting on at Christmas.

“She raised all of us by herself. She was our leader. Mum helped me when I came out of the army, I was a real mess in my mind. She sorted that. She was just an incredible woman.”

Her inquest, which took place last week, raised such concerns that assistant coroner Simon Nelson wrote to culpable parties demanding changes to prevent future deaths.

However, in yet another kick in the teeth to the family, Mr Nelson, wrongly addressed the letter to Wrightington, Wigan and Leigh NHS Trust - which has nothing to do with the services used by Angela and her son.

Bridgewater Community Healthcare NHS Foundation Trust which runs Leigh walk-in, has been informed of the findings.

In his report, Mr Nelson said: “On the afternoon of Saturday 30th December 2017 having complained of intense pain following a sudden onset headache the son of the deceased telephoned 111.

“His call remained unanswered for approximately 45 minutes. He was subsequently advised by his mother’s GP practice to attend the local walk-in-centre where, although appropriately triaged, her subsequent assessment proved suboptimal and she was inappropriately discharged home.

“On the 31st December 2017 at approximately 3.30pm she was discovered collapsed at home. A subsequent CT scan confirmed a subarachnoid haemorrhage from which she died on January 10th.”

Mr Nelson said: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you that a wholly inadequate response was made to the call made to NHS 111 on the afternoon of 30th December 2017.

“In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action.”

A spokesperson for Bridgewater Community Healthcare NHS Foundation Trust said: “We would like to apologise to the family and friends and offer our sincere sympathies at this distressing time.

“We take the findings of this coroner’s report extremely seriously and we have learned lessons from it.

“We have worked with our staff to implement the recommendations and review our systems and processes in order to make the necessary improvements so we provide the highest quality care.”

Following Angela’s inquest, which determined that she died of “natural causes” from the result of the subarachnoid haemorrhage, Skott has spoken out on behalf the family.

“It’s not enough,” he said. “What they have done and what’s been said at the inquest - it’s not enough.

“It’s not enough to mitigate the severity of this whole thing, that my mum was neglected from beginning to end and that she should still be alive.”