A hospital has been forced to apologize after a heartbroken family alleged that failing to monitor her mother’s fluid intake led to her death.
They believe kidney patient Jen Clowes “suffocated” because she wasn’t measuring and monitoring her fluid intake and output, which they say ultimately led to her death.
One of her daughters said: “My mum didn’t die when she got to Crosshouse Hospital, but she died because she got there.
“If I had any inkling that she wouldn’t come back from the hospital, I would never have let her in, we would have taken care of her at home.
“She had anything but a good death.”
Margaret said: “I was calling the hospital and they told me she was fine, but the hospital notes were telling me she was fine, but they ignored the national early warning signs.
“When nurses take an OBS, they look at heart rate, temperature, oxygen saturation levels and respiratory rate. My mom scored really high on satiety levels and heart rate.
“When my mother came to Crosshouse she should have at least been admitted to HDU.”
Jen, 91, was diagnosed in 2020 with a condition called inappropriate anticoagulation hormone syndrome, which prevents her kidneys from emptying fluids properly.
Because of her condition, she is only allowed one liter of fluids a day, including drinks, soups, puddings and gravy, and her production must be closely monitored.
Margaret, 59, said: “She needed to go to hospital to get rid of the horrible fluid build-up.
“I was always on the phone to Crosshouse Hospital asking how she was and what they were giving her for fluids.
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“They told me they were treating my mom for an exacerbation of COPD because of the shortness of breath she was experiencing.
“But my mother was diagnosed with COPD years ago as a smoker, but she never needed treatment and hasn’t smoked in 50 years.”
Margaret, a registered nurse, asked to speak to the charge nurse and explained the family’s concerns.
“As a family we took care of mother 24 hours a day. She was scared to death and we always made sure someone was with her.
“I explained it to the nurse and told her that my mother was scared and that she could die in there and no one in her family would see.”
The nurse said Margaret would be here in half an hour.
“My mother was lying in bed, but she was very mentally alert.”
That same day, a doctor phoned to say that Margaret had returned to the hospital because she was not responding to treatment.
“She was unconscious when I got to the hospital and never regained consciousness and died the same day.
“When we got her death certificate it said an exacerbation of COPD but I disagreed with that.
“I could clearly see that when she was admitted with low sodium before, her nursing rate was 96 percent, which you would never see with someone with COPD. She never needed oxygen.
“She was really fit, she walked about a mile to her job and only gave up her job when she was 76. This is not indicative of someone with COPD.”
But Margaret was really worried because when she asked to see her mother’s fluid balance chart, she couldn’t find it in her notes.
“Her notes only had one chart and it was blank but had a note on it that said ‘encourage fluids’.
“My mother was given a cup of tea in the morning, at noon, then in the afternoon and every afternoon.”
She said: “My mother suffocated to death because of it.
“A cup of tea is 250 ml, you measure it, then measure the amount of urine. We did it at home.
“If I’m looking after someone like her on a ward and I forget to record it I can expect to be pulled in and warned and suspended if I keep doing it.
“It’s a very basic tool, but it’s a lifesaver. Despite her condition, fluid build-up, they did not monitor her fluid.
“I can’t believe she died of something that had never bothered her before.
“Inappropriate anticonvulsant hormone syndrome can lead to coma and death if not treated properly.
“The hospital didn’t take all the steps to save her life and I think it was only because of her age that she was treated as a burden.
“If someone had the same health condition in their forties, they wouldn’t die. My mother was not someone who waited to die.
“She was a widow from the age of 36 and raised five children on her own. She lived for us, her grandchildren and great-grandchildren.
The family complained to the ombudsman and he instructed the health board to apologize for failing to correctly complete a fluid chart he carried out last month.
But Margaret said: “Not having a fluid chart meant they couldn’t know if she had had too much. In the end all her symptoms point to her death being reduced to the present.
Clare Burden, chief executive of NHS Ayrshire & Arran, said: “We are sorry that the high standards we strive for at NHS Ayrshire & Arran were not met for this patient.
“We have issued a formal apology to the family and will ensure that all recommendations highlighted in the Scottish Public Service Ombudsman (SPSO) report are implemented.
“The report’s findings, recommendations and learnings will be shared widely to ensure organizational learning is also implemented.”
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