Handling error by ambulance technician contributed to Grandmother’s death

The death of a grandmother was contributed to by an ambulance technician using the wrong lifting technique causing her to fall and break her leg, an inquest has concluded.

Doreen Pilling, 93, died after the technician attempted to lift her with a rolled-up towel instead of following the approved safety procedure and using authorised equipment from the ambulance.

As a result of the lift Doreen, from Burnley, fell to the floor in what was described as an “uncontrolled descent”, on 3 September 2023, and fractured her right leg.

At the inquest into her death, held at Preston Coroner’s Court on 10 April, Coroner Christopher Long concluded it was a “culpable human failure which contributed to Doreen’s death”.

Doreen was taken to the Royal Blackburn Hospital, where she developed pneumonia.

After a long stay at Blackburn, and latterly Pendle Community Hospital, Doreen died on 24 October 2023.

In his narrative conclusion, Coroner Christopher Long said: “Doreen Pilling died on October 24, 2023, at Royal Blackburn Hospital.

"An ambulance was called to assist Mrs Pilling at her home as she was unable to mobilise.

“She received a fracture of the right distal femur when the crew used an unapproved method to lift her, resulting in an uncontrolled descent to the floor, causing the fracture.

“She was taken to hospital where, after a long stay, she remained unwell with very limited mobility, which contributed to the development of pneumonia from which she did not recover.”

Christine Fitzpatrick, 66, Doreen’s daughter, said: “As a family we are grateful to the coroner for considering my mum’s care so carefully and for reaching this conclusion, which we believe is the right one.

"Watching my mum suffer for so many weeks and die in such an undignified and distressing manner was truly harrowing, and something we will never fully recover from.

"My mum was a lovely lady who gave so much to her family and local community in her life, and she deserved so much better.

"I hope that changes can be put in place to ensure the same poor care is not repeated for another patient in the same situation.”

Christine also raised concerns about Doreen’s hospital treatment, which she made an official complaint about as she felt this was very poor.

While the coroner did not find that this played a role in Doreen’s death, he did have sufficient concerns about the accuracy of the nursing charts at the Royal Blackburn to direct the hospital to provide full details within 28 days of how the charts are audited and checked to ensure adequate monitoring.

If the coroner is not satisfied with Blackburn’s response, or if they miss this deadline, he has the power to make a Prevention of Future Deaths Regulation 28 report against the hospital.

A previously fiercely independent Doreen was a food technology teacher at Burnley College during her working life where she taught adults with learning disabilities.

Before her death, Doreen lived in her own flat in the Townfields retirement complex in Burnley.

While her family helped her with her shopping, Doreen cooked all her own meals and enjoyed going out regularly for coffee.

She had previously been a Salvation Army Soldier after her husband Ken’s death in 2008 and had enjoyed delivering food parcels to Burnley people on Christmas Day.

Madeleine Langmead, a medical negligence solicitor at JMW who is handling the family’s legal case, said: “I welcome the inquest findings, as they give much needed answers to Doreen’s family.

"They witnessed her severe decline and the coroner’s conclusion confirms their belief that this all began with the careless mistake of the ambulance technician.

"This case highlights the catastrophic consequences that can occur from not following safety procedures when handling and lifting patients.

"This reckless approach should never have been taken with any patient, let alone an elderly person at increased risk of breaking a bone.

"It is vital that lessons are learned so that this doesn’t happen again.”

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