A&E doctor ‘refused’ to see woman before she died

A senior doctor refused to see a woman who died of an asthma attack after 39 hours sitting in a chair in A&E, an inquest heard.

Marina Young died at the Royal Preston Hospital on 22 June 2022 after a “gross failure to provide adequate assessment and medical care”.

The inquest in Preston heard a senior doctor had refused to see her even though her life was at risk, coroner Dr James Adeley said.

He concluded her death at the age of 46 due to asthma was “preventable”.

Lancashire senior coroner Dr Adeley said the lack of a complete report into what had happened meant “insufficient action… to rectify these difficulties” had been taken by the trust over the last two years.

“This is unlikely to be a singular occurrence and there appears to be a risk of other deaths occurring in similar circumstances,” he added.

He said he would make recommendations of how future deaths should be prevented.

Speaking after the conclusion of the inquest, held in Preston, Marina’s sister, Michelle Young, said hospital staff had “failed her fundamentally on every level”.

“The very very bottom level of basic human needs, let alone care, was not fulfilled,” she added.

The coroner told the inquest the first doctor from the hospital’s acute medical team to see Marina was a second year medical trainee, who failed to carry out a peak flow test because she “couldn’t find” the device needed.

Dr Adeley said the explanation for the missed test had been “wholly inadequate” and the doctor had accepted failing to refer Marina to more senior doctors was “quite a serious error”.

A senior doctor “refused” to see Marina for five hours after a senior nurse had asked them to, despite tests revealing her illness was in a “life-threatening category”, the coroner said.

He told the hearing that the doctor’s “refusal” to attend was one of a number of “extremely worrying” factors.

The coroner concluded there had been a “consistent failure” to consider information in Marina’s medical records and information that her sister, who had previously worked as a nurse, had written down when she was admitted.

The inquest heard Marina, who was from Ribbleton and had spina bifida, was unable to go to the toilet or remove her shoes.

This caused intense pain if she wore them for too long when an asthma attack was taking place.

Dr Adeley said “one of the saddest and most upsetting aspects” of Marina’s case was that she was still wearing shoes when her sister saw her after she had died, despite the pain it would have caused her.

“I could smell urine. It was so strong it was awful,” her sister Michelle told her inquest.

The coroner said a box had consistently been ticked on a form in Marina’s records indicating that her hygiene needs had been met, despite there being no evidence she had been given any help to use the toilet.

The form was “little more than a tick box exercise”, he told the hearing.

Family solicitor Madeleine Langmead, from law firm JMW, said: “Marina’s case is likely to have implications for the treatment of other vulnerable patients, particularly those suffering an asthma attack and should improve their patient safety.”