Apology after doctors at QEQM Hospital in Margate wrongly placed patient on ‘dying plan’
Published: 05:00, 22 August 2023
Updated: 13:27, 22 August 2023
A grandmother said her final farewells to loved ones after a hospital blunder saw her put on a ward for dying patients and denied life-saving medication by confused doctors.
Traumatised Jean Kelly, from Whitstable, even handed over “special jewellery” she had been saving for her grandchildren as they came to say goodbye to her at the QEQM in Margate.
The retired teacher, 77, had been at the hospital for two months and was seriously ill with pneumonia and respiratory complications at the end of June.
Despite still being on antibiotics in the hope she would beat the infection, she was moved into a room normally reserved for end-of-life patients to give her and her family more “privacy”.
But a team of on-call medics misunderstood the reason behind the transfer and started Jean on a “care of dying” plan, withdrawing her medication and telling her to invite family and friends - and even her beloved dog - in to say goodbye.
But no sooner had they left her side after tearful farewells the following day that two junior doctors Jean had grown to know realised a serious mistake had been made.
Shortly after, her antibiotics and steroids were restored and, after showing some improvements, she was allowed home three days later.
East Kent Hospitals, which runs the QEQM, has now apologised “sincerely”, admitting Jean should never have been transferred to the end-of-life ward or had her medication stopped.
Jean, whose three children and eight grandchildren visited her to say goodbye, remembers the harrowing moment she realised she was being told she would soon die.
“The doctor told us to get the family in and I said ‘I haven’t seen my dog in nine weeks’, and he told us we could bring the dog in to see me,” she said.
“That’s when we knew what he was saying.
“It was a horrible day. All my family and friends came to say goodbye. I gave my grandchildren some special jewellery I’d been saving. I was sure I was going to die. I had been very ill.”
While Jean was told radiography she had undergone for lung cancer had returned positive results, her pleurisy, fibrosis and the damage done to her lungs through two bouts of hospital pneumonia and various other infections mean she is aware she may not have long left to live.
In spite of this, and with the support of her palliative care team, she is trying to make the most of the precious time she has left with her family.
“We don’t know how long I’ve got left, in fact nobody seems to,” she said.
“We do accept that it is terminal but they’ve told me I could have days, weeks or longer, and now I’ve been home for over a month. Crazy.
“I just wanted to know why it happened, how it had happened and I’d like it not to happen to anybody else.
“I have a family to fight my corner and a voice, but for someone on their own they would be dead now. How could that happen? QEQM is a scary place to be if you’re not well.
“It was horrible and just so scary. They told me I was dying. It was just so surreal.”
Jean and her husband Bob had planned to marry on July 1 - Jean’s birthday and the day she said her goodbyes to loved ones.
But after Bob learned he had prostate cancer on December 31 last year the pair decided to tie the knot at a register office in February.
They planned to keep the July booking to celebrate their union with all their friends and family, but when the date arrived it was Jean who was in hospital.
Following their ordeal, the family lodged a formal complaint with the hospital in the hope of preventing other families suffering the same experiences.
They received a response on Thursday, a day after KentOnline approached East Kent Hospitals for a comment.
In it the Trust said it wanted to “sincerely apologise” for the care Mrs Kelly received, and the “distress and concern” it had caused her and her family.
It says Mrs Kelly was moved to a room on an end-of-life ward on June 30 to give her more privacy to see her family, as she was seriously unwell but still being actively treated with antibiotics and steroids in the hope she would get better.
The transfer was made despite the fact the agreed policy for admission is that “the patient, family and medical team are all in agreement that there is no further reversible or treatable condition and the focus of care is on dignified palliative and end-of-life care”.
While it was stated her treatment should continue, the Trust says an on-call medical doctor and nursing staff on the general ward where Mrs Kelly had been staying “misunderstood the plan of care that had been recorded” and started her on an end-of-life care plan.
“This should not have happened,” it said.
“Once you had moved to [the private room] the night nurses and another on-call doctor also appear to have misunderstood your plan of care, and they stopped your antibiotics on the evening of June 30.
“This should not have happened and we are very, very sorry for this.”
The Trust says Mrs Kelly’s medication was restored after the error was spotted by the junior doctors and a palliative care nurse, who are credited for potentially saving her life.
It said: “We recognise that had it not been for the quick actions of the two junior doctors and palliative care [nurse] in recognising on July 1 that your antibiotics had stopped and should not have been, you may have been much more unwell and the outcome uncertain.”
The Trust says it has discussed the importance of adhering to the policy of admission to the ward for end-of-life patients.
It will also carry out an After Action Review, comparing what happened with what should have happened to identify what can be improved in the future.
Earlier this year East Kent Hospitals said it was “truly sorry” for failings in the care of a grandmother who died at the William Harvey Hospital in Ashford.
Hazel Turner, 86, was made “nil by mouth” by doctors - denying her oral nutrition and hydration - without her family being told.
She died on September 29, 2015, having had no fluids for 48 hours and just one meal in seven days, which had been fed to her by her son, who was unaware of the doctors’ orders.
She was officially ruled to have died from pneumonia, but a retired consultant giving expert opinion during a police investigation suggested dehydration could have been the “principal cause” of her death, and at least a contributory factor.
The case was later examined in a damning report shining a spotlight on failures in end-of-life care.
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Ruth Cassidy