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An anxious and confused grandmother died after she suffocated herself in hospital while awaiting results of a cancer test.
Phillippa Vickers had been admitted to Maidstone Hospital suffering from weight loss and a deteriorating mental state in April last year and underwent a series of tests to establish the nature of her illness.
Doctors suspected the 76-year-old Staplehurst housewife might have a form of cancer, and she underwent a CT scan with the aim of establishing if this was the case.
The results of the test arrived at around 3pm on April 25, but as the day's ward rounds had already been completed Mrs Vickers was not told the positive news immediately.
A two-day inquest held at the Shepway Centre in Maidstone heard how shortly after 5am the next day, nurse Olusola Abiodun discovered her lying unresponsive on the floor beside her bed.
Despite eight rounds of CPR she was unable to be saved.
Mrs Vickers had been into hospital for tests a week earlier on April 18 but, the inquest heard, had returned home "a changed person" who was growing increasingly anxious and unable to care for herself.
'She was in a heightened state of anxiety...'
Her daughter Sophie Harvey contacted NHS 111 about her concerns for her mother's health on April 20, and the doctor she spoke to recommended she be immediately admitted to Maidstone Hospital.
She arrived on the Pye Oliver Ward, a 28-bed unit at the Hermitage Lane hospital, with a body mass index of just 13.5 and was worryingly malnourished.
Doctors who saw her in the days between her admission and her death focused almost exclusively on finding an organic condition to attribute her illness to, but her family believe more care should have been taken to examine the mental causes of her anxiety and confusion.
They say concerns raised by both the family and fellow patients on the ward about her worsening mental state - which saw her increasingly anxious at the thought of incontinence, and repeatedly packing and unpacking her bags - were not properly communicated by nurses to the relevant doctors.
"Staff and fellow patients were trying to reassure her she is going to be supported," fellow patient Vanessa Davis-Smith said in a statement read to the court. "She was in a heightened state of anxiety."
'It is most unfortunate that Phillippa was not told...'
A dietician had also advised she be administered supplements and multivitamins in a bid to address her malnourishment and dehydration. However, despite requests that food charts were completed, there was no clear evidence that this advice was followed through.
On the day before she died, Mrs Vickers had consumed just 150ml of fluid - hot chocolate given to her on the ward by a member of staff - and would have been significantly dehydrated.
The inquest heard that Mrs Vickers had spoken to her daughter about how she "did not want to be here any more", but in her narrative finding assistant coroner Sonia Hayes said she could not see that on the balance of probabilities she had intended to end her life.
Reflecting on the evidence given suggesting the results of her tests were "tantalisingly close", Ms Hayes said: "It is most unfortunate that Phillippa was not told."
Cause of death was given as cerebral hypoxia caused by suffocation and an undiagnosed delirium, which had altered the deceased's cognitive function.
'The tools for diagnosis are far from perfect...'
Carin Hunt, counsel representing Mrs Vickers' family, had in submission to the coroner requested that a finding of neglect be considered, however Ms Hayes said that threshold could not be met as it would require there to be evidence of "gross failure" on the part of the Maidstone and Tunbridge Wells NHS Trust.
A statement released by the family's lawyers following the inquest said: "My clients are pleased and relieved that the truth has now come to light in the form of the coroner's findings about Phillippa's death.
"The coroner has enabled the concerns they had about Phillippa’s wellbeing and care in hospital to be finally acknowledged and has recognised the hospital's failures in care. The family feel very let down by Maidstone and Tunbridge Wells NHS Trust.
"It is evident that junior doctors frequently fail to diagnose delirium and that the tools for diagnosis are far from perfect. The family hope that lessons can be learnt from Phillippa’s premature and tragic death and that hospital staff will receive better training in awareness, diagnosis and management of delirium so that no other families have to suffer."
Ms Hayes expressed criticism of communication between staff and the completion of requests for recording food intake by the patient. She told the hearing she would consider writing a Regulation 28 report outlining any action she believes could be taken to help prevent further deaths in future.
A spokesman for Maidstone and Tunbridge Wells NHS Trust said: "This is a sad and tragic case and we offer our heartfelt and deepest sympathies to the family and friends of Phillippa Vickers.
"While no words can adequately address their loss, we will review any findings the coroner may raise."
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