The call came at a time when UK hospital beds have hit a record low in light of NHS funding crisis. Reports show that last year, 237 patients had to wait for over 12 hours for a bed at a London hospital.
In her letter to NHS England, North London coroner Mary Hassell said, “In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.”
The coroner believed that “with prompt transfer and surgery, she’d probably have survived.”
Lack of beds at NHS hospitalsMary Muldowney, a mother of two from West Sussex, was first taken to East Surrey Hospital where a CT scan showed heavy bleeding, and doctors requested for an immediate transfer to a specialist neurological unit for surgery.
However, the three hospitals - Brighton’s Royal Sussex County Hospital, St George’s Hospital and King’s College Hospital - were unable to admit her as they were short of intensive care beds.
According to Hassell, in desperation, “one of the East Surrey Hospital doctors went out of area and rang a consultant neurosurgeon at the Royal London Hospital (RLH).”
“Invoking the universal acceptance policy, he accepted transfer immediately, though in fact the RLH had no intensive care bed available at that time,” said Hassell.
Muldowney was taken straight to the operating theatre at 4.40pm. However, the surgery could not save her as “her pupils had become fixed and dilated in the ambulance during the transfer.”
Hassell stressed that Muldowney should have been moved immediately for the operation, while an intensive care bed could be found afterwards.
A clear "difference in perspective" between doctors at different hospitalsMuldowney’s death has raised concerns about the unstandardised protocols of patient care. NHS England chief Bruce Keogh noted the “difference in perspective” between doctors at East Surrey Hospital and St George’s Hospital, and that the two clinicians involved will meet to review the case and establish new protocols regarding patient safety.
Keogh said that Simon Mackenzie, a doctor from St George's Hospital, had suggested Muldowney "was not deemed by the neurosurgical services to which she was being referred to require immediate life-saving surgery" and fell outside the scope of the universal acceptance policy.
In his statement, Keogh wrote that Mackenzie said that "although at the time of the referral to the St George's neurosurgical unit a re-bleed was a possibility, this was not the reason for her urgent transfer.” But the process of securing a bed added a delay of just less than two hours to the acceptance process.
A spokesman for St George's Hospital said that the neurosurgical department operates a ‘universal acceptance policy’, however, "Unfortunately, at the time of referral, Ms Muldowney was not deemed to require life-saving surgery which led to her transfer to Royal London Hospital.”
Brighton and Sussex University Hospitals NHS Trust echoed the same reason, saying that there was no indication that emergency transfer was required. King's College Hospital stated that patient transfers are only accepted when medical specialists have been consulted and it is clinically safe. MIMS
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