Lancashire TelegraphPatient died after procedure slip-up at Royal Blackburn Hospital (From Lancashire Telegraph)

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Patient died after procedure slip-up at Royal Blackburn Hospital

Lancashire Telegraph: Royal Blackburn Hospital Royal Blackburn Hospital

STAFF at the Royal Blackburn Hospital ‘failed to follow protocol’ after a cancer patient, who later died, was admitted, an inquest heard.

Retired milkman Roy Wildman, who lived in Lime Street, Nelson, fell ill after undergoing chemotherapy aimed at prolonging his life. He died from an infection on Monday, May 5.

Blackburn Coroner’s Court heard how it took two days for staff in A&E to inform cancer doctors of his arrival when it should have been done immediately.

Coroner Michael Singleton said he had hoped to question an oncologist from the hospital about Mr Wildman’s death.

Last week he asked for a review of emergency admission procedures relating to the triage of patients suffering from cancer during the inquest of another patient.

Mr Singleton said: “I required Dr Appel to come today, but unfortunately, and at short notice, she couldn’t come.

“I know the hospital has a protocol which is, if anybody attends A&E and they are currently in chemotherapy, they should be started on antibiotics, and the on-call oncologist should be informed immediately. I can tell you one concern is that evidently protocol is not followed. I’m assuming they gave antibiotics immediately, and did a blood count, and specimens were sent to a microbiologist to advice on the appropriate antibiotics scheme.”

Mr Singleton said he did not believe the delay contributed to Mr Wildman’s death, and offered Mr Wildman’s family the opportunity to adjourn the hearing until a later date when Dr Appel could attend.

When they declined, he recorded a narrative verdict, and said Mr Wildman died from neutropenic sepsis, a complication of anti-cancer treatment, with lung disease a contributing factor.

Speaking after the inquest, David Tansley, associate director of Quality and Safety at the trust, said: “Firstly, we offer our sympathies to Mr Wildman’s family.

“Patients known to be receiving chemotherapy who are admitted via the Emergency Department trigger a notification to the Oncology team.

“It would appear that on this occasion this did not happen.

“We have launched an investigation, which is now under way.

“That being the case, we cannot comment further at this time.”

Comments (17)

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9:29am Tue 8 Jul 14

Mikeee47 says...

yet another failure for a Special measures Hospital, when is someone going to be put in place to run these departments as they should?
yet another failure for a Special measures Hospital, when is someone going to be put in place to run these departments as they should? Mikeee47
  • Score: 25

9:47am Tue 8 Jul 14

GracesDad says...

Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death.
Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death. GracesDad
  • Score: -13

10:12am Tue 8 Jul 14

vicn1956 says...

New day new controversy!
New day new controversy! vicn1956
  • Score: 13

10:27am Tue 8 Jul 14

vicn1956 says...

lessons will be learned
lessons will be learned
lessons will be learned

they need to find a new mantra

protocols were not followed
people are going to say I don't want to go to hospital-I remember my granddad saying that 50 years ago when they were right to be afraid
lessons will be learned lessons will be learned lessons will be learned they need to find a new mantra protocols were not followed people are going to say I don't want to go to hospital-I remember my granddad saying that 50 years ago when they were right to be afraid vicn1956
  • Score: 18

12:36pm Tue 8 Jul 14

Mikeee47 says...

GracesDad wrote:
Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death.
lets hope it's not one of your family they make the next mistake on then?
I wonder If you'll have the same attitude?
We know mistakes happen, but far too many in this Hospital by Trained Professionals, or are they??
I for one would be sacked in my job if made a critical error, then again I would probably be dead too
[quote][p][bold]GracesDad[/bold] wrote: Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death.[/p][/quote]lets hope it's not one of your family they make the next mistake on then? I wonder If you'll have the same attitude? We know mistakes happen, but far too many in this Hospital by Trained Professionals, or are they?? I for one would be sacked in my job if made a critical error, then again I would probably be dead too Mikeee47
  • Score: 14

12:52pm Tue 8 Jul 14

Angelistic says...

It appears that my comment about poor attitudes of staff and care levels (by some departments - not all) has been deleted by the "gods". I only stated facts that my father and his conditions were regularly "forgotten" when he was admitted. I also stated that some departments are brilliant and others are terrible BUT hey ho it appears that my opinion - which I am entitled to - doesn't cut it with the LT!
It appears that my comment about poor attitudes of staff and care levels (by some departments - not all) has been deleted by the "gods". I only stated facts that my father and his conditions were regularly "forgotten" when he was admitted. I also stated that some departments are brilliant and others are terrible BUT hey ho it appears that my opinion - which I am entitled to - doesn't cut it with the LT! Angelistic
  • Score: 13

1:17pm Tue 8 Jul 14

GracesDad says...

Mikeee47 wrote:
GracesDad wrote:
Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death.
lets hope it's not one of your family they make the next mistake on then?
I wonder If you'll have the same attitude?
We know mistakes happen, but far too many in this Hospital by Trained Professionals, or are they??
I for one would be sacked in my job if made a critical error, then again I would probably be dead too
Been there. I had a daughter that was born with a genetic defect and during her 5 years of life, I witnessed many mistakes by the staff at Royal Blackburn Hospital.

But I accept that people make mistakes. We are human and will never be perfect. The way some people on here post, you would assume that most of the staff in hospitals take up the job to cause problems.
[quote][p][bold]Mikeee47[/bold] wrote: [quote][p][bold]GracesDad[/bold] wrote: Unfortunately, the unit is run by human beings not robots, therefore mistakes will happen. I do not know anybody who has never made a mistake in their life but obviously mistakes made in the health sector can lead to death.[/p][/quote]lets hope it's not one of your family they make the next mistake on then? I wonder If you'll have the same attitude? We know mistakes happen, but far too many in this Hospital by Trained Professionals, or are they?? I for one would be sacked in my job if made a critical error, then again I would probably be dead too[/p][/quote]Been there. I had a daughter that was born with a genetic defect and during her 5 years of life, I witnessed many mistakes by the staff at Royal Blackburn Hospital. But I accept that people make mistakes. We are human and will never be perfect. The way some people on here post, you would assume that most of the staff in hospitals take up the job to cause problems. GracesDad
  • Score: 2

1:26pm Tue 8 Jul 14

Pendlesider says...

QUOTE: "Coroner Michael Singleton said he had hoped to question an oncologist from the hospital about Mr Wildman’s death. "
.
the coronor's no chance, it took 2 days for A&E staff to notify a doctor of the poor fellas arrival. they can't afford to make mistales and a few may be acceptable but this special measures hospital are making mistakes that cost lives. there's no chance of this trust getting foundation status never mind out of special measures. It's the worst hospital ever to appear in Lancashire. Go google 'clinical negligence lawyer' and maybe they'll make fewer mistakes,,, but i doubt it.
QUOTE: "Coroner Michael Singleton said he had hoped to question an oncologist from the hospital about Mr Wildman’s death. " . the coronor's no chance, it took 2 days for A&E staff to notify a doctor of the poor fellas arrival. they can't afford to make mistales and a few may be acceptable but this special measures hospital are making mistakes that cost lives. there's no chance of this trust getting foundation status never mind out of special measures. It's the worst hospital ever to appear in Lancashire. Go google 'clinical negligence lawyer' and maybe they'll make fewer mistakes,,, but i doubt it. Pendlesider
  • Score: 6

1:51pm Tue 8 Jul 14

anuttall60@googlemail.com says...

My Dad also Died in the same way, at Blackburn and with the same Doctor. I still say that the delay in treatment caused my Dads death. Lessons have not been learnt even after the coroner had put a rule43 into place. It makes me very sad that this has happened again, when will things get better if ever. I just hope that me and the rest of my family don't have to be treated there.
My Dad also Died in the same way, at Blackburn and with the same Doctor. I still say that the delay in treatment caused my Dads death. Lessons have not been learnt even after the coroner had put a rule43 into place. It makes me very sad that this has happened again, when will things get better if ever. I just hope that me and the rest of my family don't have to be treated there. anuttall60@googlemail.com
  • Score: 9

2:12pm Tue 8 Jul 14

Benpupdog says...

It's very sad I agree, but these surgeons are human as well and therefore make mistakes. LT maybe you can help by reporting on the amount of people's lives they save instead of applying more pressure by only reporting on incidents like this. Let's face it if there was a fatality every time you made a mistake or miss spelled a word half the inhabitants of Lancashire would be dead.
It's very sad I agree, but these surgeons are human as well and therefore make mistakes. LT maybe you can help by reporting on the amount of people's lives they save instead of applying more pressure by only reporting on incidents like this. Let's face it if there was a fatality every time you made a mistake or miss spelled a word half the inhabitants of Lancashire would be dead. Benpupdog
  • Score: 3

5:39pm Tue 8 Jul 14

zabby says...

Third world doctors provide third world care,this is a new labour flagship hospital,correct me if I'm wrong.hospitals need to be more localised I'm sure things were better before this so called super hospital existed
Third world doctors provide third world care,this is a new labour flagship hospital,correct me if I'm wrong.hospitals need to be more localised I'm sure things were better before this so called super hospital existed zabby
  • Score: 3

6:37pm Tue 8 Jul 14

woolywords says...

Angelistic wrote:
It appears that my comment about poor attitudes of staff and care levels (by some departments - not all) has been deleted by the "gods". I only stated facts that my father and his conditions were regularly "forgotten" when he was admitted. I also stated that some departments are brilliant and others are terrible BUT hey ho it appears that my opinion - which I am entitled to - doesn't cut it with the LT!
I saw that,
but it wasn't here.
[quote][p][bold]Angelistic[/bold] wrote: It appears that my comment about poor attitudes of staff and care levels (by some departments - not all) has been deleted by the "gods". I only stated facts that my father and his conditions were regularly "forgotten" when he was admitted. I also stated that some departments are brilliant and others are terrible BUT hey ho it appears that my opinion - which I am entitled to - doesn't cut it with the LT![/p][/quote]I saw that, but it wasn't here. woolywords
  • Score: 0

6:47pm Tue 8 Jul 14

Polly76 says...

I agree with some of the posts above people are only human and do make mistakes, but when mistakes are made you expect lessons to be learnt and the same mistakes not to be made again. When reading the above report I had to double check a number of times that it was not related to the death of my grandad last year, it reads identical even down to the DR's involved so when the coroner ruled special measures to be put in to place last year why has this happened again to another person? Serious questions need to be asked, as a family all we asked was for measures to be put in to place to stop this happening to another family, its appalling to read its happened again.
I agree with some of the posts above people are only human and do make mistakes, but when mistakes are made you expect lessons to be learnt and the same mistakes not to be made again. When reading the above report I had to double check a number of times that it was not related to the death of my grandad last year, it reads identical even down to the DR's involved so when the coroner ruled special measures to be put in to place last year why has this happened again to another person? Serious questions need to be asked, as a family all we asked was for measures to be put in to place to stop this happening to another family, its appalling to read its happened again. Polly76
  • Score: 3

7:35pm Tue 8 Jul 14

noddy57 says...

This is unacceptable in this day and age.Hospitals are supposed to save people not kill them.
This is unacceptable in this day and age.Hospitals are supposed to save people not kill them. noddy57
  • Score: 0

7:47pm Tue 8 Jul 14

kapalski says...

Cure the nhs or should I say cure ELHT we need a person like Julie Bailey to represent the people of Lancashire!!

They are clearly not learning from any mistakes they are making, but they are not little mistakes are they? It's people's lives.

Yes we are all human, and mistakes happen, but when dealing with people's health more care and attention should be paid at all times so mistakes like this do not happen.

I've said it before and I'll say it again, I'm thankful to the LT for highlighting the failures of this place, the LT should not have to publish stories on the lives saved as this is what is expected of a hospital!!

First do no harm, or does that not apply now?
Cure the nhs or should I say cure ELHT we need a person like Julie Bailey to represent the people of Lancashire!! They are clearly not learning from any mistakes they are making, but they are not little mistakes are they? It's people's lives. Yes we are all human, and mistakes happen, but when dealing with people's health more care and attention should be paid at all times so mistakes like this do not happen. I've said it before and I'll say it again, I'm thankful to the LT for highlighting the failures of this place, the LT should not have to publish stories on the lives saved as this is what is expected of a hospital!! First do no harm, or does that not apply now? kapalski
  • Score: 3

10:05pm Tue 8 Jul 14

kto says...

Why is Dr Appels name being dragged into this report? It states that Dr Appel, the on call oncologist was NOT informed, therefore the people to blame are the staff who dealt with Mr Wildman when he presented and they failed to inform the Acute Oncology Team.
Why is Dr Appels name being dragged into this report? It states that Dr Appel, the on call oncologist was NOT informed, therefore the people to blame are the staff who dealt with Mr Wildman when he presented and they failed to inform the Acute Oncology Team. kto
  • Score: 5

10:39am Wed 9 Jul 14

Hena says...

I have experienced the same illness whilst on chemotherapy. I knew within 2 hours of feeling unwell and taking my own temperature that I needed to get help. I was not withing the oncology/chemotherap
y unit opening hours and therefore rang the MAU at RBH. I was asked to go straight to the unit, and within an hour was admitted where I spent 5 nights being treat for neutropenic sepsis. The point I would like to make is why did Mr Wildman not alert anyone about feeling ill until far too late? The golden rule when on chemotherapy is to alert medical staff when you START feeling ill...to be admitted to A&E seems like he waited too long. You cannot blame the A&E staff, nor Dr Appel (my own oncologist) as to me; in my opinion, anti biotics were administered correctly, but infection with another underlying health problem and his age (retired) hampered possible recovery.
I have experienced the same illness whilst on chemotherapy. I knew within 2 hours of feeling unwell and taking my own temperature that I needed to get help. I was not withing the oncology/chemotherap y unit opening hours and therefore rang the MAU at RBH. I was asked to go straight to the unit, and within an hour was admitted where I spent 5 nights being treat for neutropenic sepsis. The point I would like to make is why did Mr Wildman not alert anyone about feeling ill until far too late? The golden rule when on chemotherapy is to alert medical staff when you START feeling ill...to be admitted to A&E seems like he waited too long. You cannot blame the A&E staff, nor Dr Appel (my own oncologist) as to me; in my opinion, anti biotics were administered correctly, but infection with another underlying health problem and his age (retired) hampered possible recovery. Hena
  • Score: 2

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