Heart transplant patient let down by hospital, say family

Hannah Pudsey, 24, died at Hull Royal Infirmary on February 1 last year after suffering from a condition called metabolic acidosis.

Her body was also rejecting her transplanted heart, which she had been given in 2001.

An inquest heard Miss Pudsey – who had been busy planning her wedding – had been vomiting and complained of chest pains in the days leading up to her death. She was admitted on recommendation of her GP suspected of suffering a diabetic episode.

Working on Ward 10, a diabetic ward that day, were a number of trainee and junior doctors and nurses, one of whom was on his first shift.

The inquest heard staff failed to read a letter from Miss Pudsey’s GP, which had been handed to staff by Hannah’s mother Ros, detailing her medical history.

Had the letter been opened and read in the hours leading up to her death, Miss Pudsey could have been sent to a High Dependency Unit and treated as a complex patient and been made a priority. Instead, the court heard, she was left for hours between blood tests.

Dr Suvarna, who carried out the post-mortem examination on Miss Pudsey’s body, expressed his concerns that the trust’s treatment of what they first believed to be the potentially fatal condition, diabetic ketoacidosis, was prioritised over the heart rejection.

“They should have been treated in tandem and not prioritised over one another,” Dr Suvarna said.

Upon being handed the note, speciality training registrar Dr Kanchan Manchegowda said she failed to read it. When asked by Coroner Professor Paul Marks if had she read the letter she would have acted on Hannah as a matter of urgency, she replied “Maybe, yes.”

Dr Manchegowda continued: “I didn’t get a chance to look at the information, as I was also dealing with another patient who was also suffering from a cardiac arrest. I was unaware that Hannah had been moved from the A&E department to Ward 10.

“Hannah did not complain about any heart problems to me. She was initially responding to treatment and heading in the right direction.”

In a statement, Mrs Pudsey said: “Hannah was seen by a junior doctor in the morning and transferred at 12.30pm to a diabetes ward. She was not seen by anyone senior on that ward until 4pm. By that time her condition had deteriorated.

“I was concerned that the care she was given was not sufficient. I called a doctor at 6pm when she collapsed and screamed out for oxygen.

“If Hull Royal Infirmary had acted earlier on in the day, maybe Hannah would have survived. We feel she could have survived that day.”

Dr Jane Elizabeth Patmore, consultant physician at Hull Royal Infirmary, admitted the “first decision we made was the wrong one” and said if they’d identified other issues including cardiac rejection at the start “we would have taken a different path”.

Recording a verdict of natural causes, Professor Paul Marks gave Miss Pudsey’s cause of death as metabolic acidosis and cardiac rejection.

“Admittance to the High Dependency Unit and a discussion with a cardiologist may have made a difference to the outcome, but we are unable to say for definite,” Prof Marks said. “Thus I am persuaded that there have been no missed opportunities which may have changed the outcome.

“I am satisfied that the trust initiated the appropriate measures and that there is no ongoing failure in the system.”

Mrs Pudsey said the family received a written apology from the trust’s chief executive Phil Morley, for “unacceptable mistakes and errors” in her daughter’s death.

Outside court, she said: “I’m obviously a little disappointed with the natural causes verdict as I think it would have been more a narrative verdict. In view of Phil Morley’s previous statements to say that he was sorry for the 
unacceptable mistakes that they made, I do feel we have some closure and we need to move on in our lives and start to try and rebuild it.

“I don’t feel that she was given the best quality care. She was left a long time without further blood tests being ordered, even though they knew earlier in the day that her blood results were not right.

“I was very proud of Hannah. She was absolutely fantastic and she fought for what she believed in.”