By Michael Holmes
You can also read this article on The Lead
Bosses at Blackpool Victoria Hospital have launched an urgent review after a doctor was caught filling in post-op paperwork to say a patient was recovering well - despite her not even having the procedure yet.
The systematic “pre-populating" of medical documents came to light during an inquest into the death of 36-year-old Sabina Wood, who was found lifeless in bed after discharging herself from the Whinney Heys Road hospital.
It is the latest negative headline to hit the under-fire Vic, which in recent years has been at the centre of several major scandals, including a poison plot on the stroke unit and the unsolved murder of a grandmother.
Two medics are also facing tribunals in the coming days over allegations of dishonesty and sexually motivated misconduct.
Deputy medical director Dr Steve Wiggans told
The Blackpool Lead an urgent review of “clinical practice” is underway as a “priority” after a coroner investigating Wood’s death raised the alarm about discharge papers being filled in with guesswork.
He said: “I want to send sincere condolences to Sabina’s family and friends on behalf of everyone at the trust and assure them that improvements in patient discharge summaries are being made, including how additional patient safety concerns and safeguards are incorporated into the online systems which support the care we provide.
“While this work is completed, additional safety instructions have been issued to colleagues and we have shared our learning from the case with other trusts so it is available to make improvements across the local health system.”
Wood, nee Wright, of Wingate Avenue in Anchorsholme, was admitted to hospital last January after spending months in intermittent pain, the two-day inquest, held at Blackpool town hall, was told.
After tests for gallstones, including having a camera put down her throat in a procedure known as an ERCP, the housewife discharged herself against medical advice.
Four days later, she was found unresponsive by her partner, with paramedics confirming her death after being called to her home.
Louise Rae, assistant coroner for Blackpool and Fylde, said in a regulation 28 report to the Vic’s medical director Chris Barben and health secretary Victoria Atkins, written when there is a risk of future deaths unless action is taken, that “during the course of the inquest the evidence revealed matters giving rise to concern”.
She said: “I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge.
“I found that this occurred across disciplines and hospitals given that (redacted) now works at the Royal Preston Hospital as a consultant where I heard the practice also takes place.
“The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients.”
Rae added: “In this case, (redacted) created the document on January 20 2023 before Sabina underwent the ERCP procedure (three days later).
“This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice.
“The section on ERCP was left blank, intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling.
“As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.”
The coroner continued: “I found it very concerning to hear that speculative information in Sabina’s case was placed on the discharge summary before her procedure took place.
“There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.”
Despite ruling that Wood died from natural causes, specifically acute haemorrhagic pancreatitis and gallstones, Rae said “there is a risk of deaths in the future from this practice, which is commonplace and neither medical specialism or hospital-specific”.
In a statement, the Vic’s deputy medical director Wiggans said it is “important to note that while the coroner didn’t find that this issue had contributed to Sabina’s death, we acknowledge completely the very serious concerns raised which may be material in other cases”.
On May 31, the Vic formally responded to Rae, saying a new discharge system was being put in place.
“In the interim whilst system implementation is brought to completion, the executive medical director will issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need to take care when pre-populating and that clinicians are not to prejudge any investigation results,” it said.
The Blackpool Lead asked for an interview with the Vic’s new chief executive Maggie Oldham about the culture at the hospital but was told it would breach pre-general election communications guidance.
She will have taken the job knowing about the hospital’s recent history, which has threatened to overshadow the hard and dedicated work of much of its workforce.
High-profile cases
Perhaps the most high-profile case, at least since the slaying of 26-year-old nurse Jane Clough in a hospital car park by her former partner Jonathan Vass in 2010, has been the secret sedating of stroke patients by nurses Catherine Hudson, 54, and Charlotte Wilmot, 48, so they could have an “easy shift”.
