Hospital in bed mix-up 'lost' dying teenager for an hour

Doctors caring for 17-year-old Clementine Nicholson were “astonished” that she had been taken from a resuscitation unit without their consent, Coventry Coroner’s Court heard.

The teenager, who was a boarder at Rugby School in Warwickshire, died of meningococcal septicaemia in May last year after communication failures saw her moved to two inappropriate wards rather than to intensive care.

Coventry coroner Sean McGovern identified seven failings at the hospital but he said it was not clear whether or not the failures had contributed to her death.

Giving evidence, Dr Nishant Patodi said Coventry’s University Hospital had administered treatment promptly despite initially misdiagnosing Clementine’s condition. Both antibiotics and fluids were given to the patient as she was being treated in a resuscitation unit.

But Clementine was later transferred to a clinical decisions unit, as well as another ward, and was only admitted to intensive care after a junior doctor noticed she was desperately ill and “effectively moribund”.

Dr Patodi said he could not explain why Clementine had been moved to two other wards before finally being admitted to intensive care.

Asked by counsel for Clementine’s family, Andrew Axon, to explain how a dying girl could “get lost” at the hospital, Dr Patodi replied: “I have not got any explanation – it’s certainly not what the doctors had asked for.

“I came back to (the resuscitation unit) and I was astonished.

“Our expectation was that Clementine was going to be seen by the critical care team – and after that be moved to the intensive care ward.”

Dr Mair Edmunds, associate director for clinical performance at the hospital, expressed her regret that Clementine had been moved by an electronic bed management system.

Dr Edmunds told the coroner that the hospital now had a nurse controller to oversee such moves, and that more robust procedures were now in place to ensure patients were well enough to be transferred.

“Clearly, on this occasion there was a breakdown in communication between the nursing team and the medical team,” Dr Edmunds said. “The movement of the patient is clearly something that is regrettable and should not have happened.”

In his narrative verdict, the Mr McGovern, ruled that there had been “a lack of direction and urgency” regarding Miss Nicholson’s treatment between 1.10pm and 5.45pm on May 6 last year.

The lack of urgency was characterised by seven failings, Mr McGovern said, including a failure to adhere to the hospital’s own guidelines, a decision to take an unnecessary CT Scan, and a failure to ensure that Clementine was admitted to critical care as soon as possible.

But the coroner said it was not clear whether or not the failures had contributed to the death. Mr McGovern said: “Meningococcal septicaemia is a virulent natural disease where, even with the best treatment, fatalities occur.”

After the hearing, the 17-year-old’s parents described the circumstances of her death as truly shocking.

They said: “We believe that a series of failures led to the premature death of our daughter, Clemmie.

“Nothing could have prepared us for the truly shocking evidence that we have heard over the past few days.

“We would like to thank the coroner for his thorough exploration of all the circumstances and note his highly-critical verdict.”