Family correct to raise concerns about treatment of retired joiner who died at Blackpool Victoria Hospital
PLUS: Exploring the history of the Hartes building in Blackpool
Hello and welcome to The Blackpool Lead.
Today we report on a letter sent to Blackpool Victoria Hospital by a concerned coroner after a family raised concerns over the death of a man who was receiving care.
The letter, sent by coroner Alan Wilson, aims to prevent future deaths occurring for the same reason.
We also introduce the first of our fortnightly history pieces, which are available in full for paid subscribers to The Blackpool Lead.
This week, local historian Anne Charlesworth has written about the past of the Hartes building - recently demolished - and it’s a fascinating story.
Every other Wednesday, a different history writer with specialist knowledge about an area of Blackpool will contribute to The Blackpool Lead.
We will continue to provide our news updates free for all subscribers, but the best way to support our independent journalism - and get access to everything we write - is with a paid subscription.
Coroner writes to Blackpool Victoria Hospital warning people are at risk over shortcomings in care
By Michael Holmes
A Blackpool Victoria Hospital patient’s loved ones were right to raise concerns about his treatment there, a coroner said as he warned people are being put at risk because of shortcomings in care.
The family of retired joiner and carpenter Brian Kneale, 70, said they feared fluid given to him after his admission - which left him with signs of a “fluid overload” on his chest - contributed to his worsening heart failure.
And Alan Wilson, Blackpool’s senior coroner, said in a report sent to the Vic’s chief executive Maggie Oldham: “Having heard the available evidence, I was in agreement this was probably the case…”
He added: “I have a concern that although it seems the hospital trust is aware there is an issue regarding accurate fluid balance monitoring, the current position is patients remain at risk if decisions have to be made by clinicians in the absence of accurate fluid balance charts.”
Kneale, who survived his wife Pauline, a bookkeeper, was admitted to the Vic, in Whinney Heys Road, on June 27 after being unwell for a week, being sick and short of breath.
After being examined, medics believed he had developed pneumonia and was experiencing heart failure, the inquest was told.
Wilson said in a regulation 28 report, written when there is a risk of more deaths without preventative action: “He was placed on the sepsis pathway but did not receive antibiotic therapy until the early hours of the following day.
“He was felt to be dehydrated and intravenous antibiotics were administered.
“From the available evidence, the quantity of fluids given is unclear, although by the afternoon of June 28 a portable chest X-ray revealed signs of fluid overload.
“Given that Brian had heart failure, a kidney injury and was showing signs of infection, the amount of fluids given probably contributed to worsening heart failure.
“Reviewed by an intensive treatment unit doctor, his prognosis was felt to be poor and Brian died at 9.45pm on June 29 in the presence of his family.
“A subsequent post-mortem examination confirmed he died from the combined effects of heart failure of bronchopneumonia.”
Even though the amount of fluids given to Kneale “required an element of caution”, fluid balance charts were not recorded properly, Wilson said, adding: “They did not provide a reliable picture.”
A consultant in acute medicine told the inquest he had worked during the autumn on a “piece of work with the aim of improving how fluid balances are monitored and recorded for patients in the emergency department but also the acute medical unit”, Wilson’s report said.
Although he left the Vic in October, the expert “felt some improvements had been made but he remained concerned about the position in the emergency department, which remained challenging”.
Wilson said: “I was left with the impression that clinicians were at times having to make difficult judgements in the interests of patients when they did not have a clear picture about fluid balances.
“Whether a hospital patient has been given an appropriate amount of fluids is a vital element of a patient’s care, and when this does not happen effectively for whatever reason, it can understandably cause bereaved relatives significant concern.
“I have a concern that although it seems the hospital trust is aware there is an issue regarding accurate fluid balance monitoring, the current position is patients remain at risk if decisions have to be made by clinicians in the absence of accurate fluid balance charts.”
He continued: “This issue can also have an impact upon reviews conducted internally by a hospital trust, and the extent to which these can be relied upon.
“The authors of such reviews, in the event appropriate lessons are learned, need to be able to form an accurate impression about the level of care given to patients.”
The Blackpool Lead asked Blackpool Teaching Hospitals NHS Foundation Trust, which runs the Vic, 15 questions about Wilson’s report and the treatment given to Kneale.
They included:
What specific steps have been taken since the coroner's report to address the concerns raised about fluid balance monitoring?
How will the hospital ensure clinicians are not put in situations where they have to make decisions without reliable data in the future?
Are there plans to review other patients' care to identify whether similar issues have occurred? If so, what are the findings so far?
In response, executive medical director Chris Barben said in a brief statement: “First of all I’d like to offer our deepest condolences to the family of Mr Kneale. I appreciate how difficult this time will be and I’d like to offer firm reassurances that we take the coroner's report very seriously.
“We’re now working to fully review the report and to make sure we understand the concerns raised and how the trust can work to make sure that the issues identified are quickly resolved - with action taken where it may be needed.”
Wilson’s report was sent on January 23; Oldham, the Vic’s CEO, must respond formally to it by March 22.
A 2016 study found that, in critically ill patients, fluid overload is linked to “increased mortality”, while it can also “lead to several complications”, including heart failure.
The research, by Rolando Claure-Del Granado and Ravindra Mehta and called Fluid overload in the ICU: evaluation and management, said knowing how much fluid a patient has is “essential” because not knowing can result in the wrong treatment - with either too little or too much possibly proving deadly.
But it added: “There are several methods to evaluate fluid status; however, most of the tests currently used are fairly inaccurate.”
The latest controversy at the Vic comes after The Blackpool Lead revealed how an independent review is being carried out into its new fetal medicine service after concerns were raised about ultrasound scanning and preterm clinical pathways.
The wonder of Woolie’s
By Anne Charlesworth
The recent demolition of the derelict former Hartes building on Waterloo Road marked the end of a bittersweet era. Latterly the cause of much controversy and dispute between its owner and the council, many regretted the loss of the locally-listed building but were also relieved to finally see the eyesore demolished.
Within living memory, its glory days was as a thriving Woolworth’s store which opened in 1928, serving the needs of South Shore folk for 65 years until it closed after Christmas in 1993.
Ask any former or current long-time resident of South Shore and they will nostalgically talk about the wonder of Woolie’s and how its demise is still much lamented.
However, few will know the fascinating history of the site and how it was no stranger to controversy long before recent years. Since the mid-1800s it’s provided a whole host of public amenities and witnessed illegal gambling, suicide and violence.
Read on below.
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Thank you for reading The Blackpool Lead this week.
We will write to you again on Sunday and we hope you enjoy the rest of your week.
Luke, Ed, Jamie, Mike, Sophie and the team.