A 'catalogue of disasters' meant that Elsie Westron died after spending almost four hours seriously ill in Greenwich District Hospital, south-east London, without being seen by a single doctor, Sir Montague Levine, the Southwark coroner, said.
Sir Montague added that conflicting evidence about whether her notes were available and whether her presence in casualty was properly recorded proved that either the doctors responsible for her, or the nurses, were lying.
The saga of errors began just after 4pm on 1 September this year, when Mrs Westron, of Charlton, south- east London, was admitted to casualty because no geriatric beds were free. Debbie Warley, a staff nurse, judged her to be in a critical condition, but Mrs Westron was placed in the non-acute section because the acute beds were full.
After taking Mrs Westron's pulse, blood pressure and temperature, Ms Warley bleeped Dr Phillip Simons, the doctor on call, to examine her. She was told he would be down shortly.
At 5.45pm, Ms Warley checked Mrs Westron's notes and realised Dr Simons had not yet examined her patient even though she had fever, a racing pulse, and dehydration. She bleeped Dr Simons at 5.50pm and then again at 5.55pm.
Dr Simons rang and promised he would see Mrs Westron in 20 minutes. Meanwhile, a relief nurse, Sandra Parker, decided to arrange for Mrs Westron to be transferred to a quieter general medical ward.
When Dr Simons still had not appeared after 20 minutes, Ms Parker bleeped him to tell him she was moving Mrs Westron, and again at 6.30pm when he did not reply. By 6.45pm, Mrs Westron was on her way to Ward 2B without the doctor's knowledge, the court was told.
Meanwhile Dr Simons's houseman, Dr Joe Shaffer, who had been sent down earlier, was unable to find Mrs Westron.
Dr Shaffer told the court he had arrived in casualty shortly after 5pm and had asked three uniformed staff in the department whether they had heard of Mrs Westron, but they had not. Nor could he find her notes in the file, so he and Dr Simons assumed she had not arrived at the hospital.
Dr Shaffer then examined patients on his rounds of Ward 2B at around 7pm - by which time Mrs Westron had arrived. Once again he failed to notice her and she went unexamined although only yards away. At 7.45pm she was dead.
Recording a verdict of death by natural causes, Sir Montague said he was unable to say Mrs Westron's death had been directly aggravated by lack of care, but that did not change the fact that Mrs Westron was the victim of an 'appalling state of affairs'. He called for the opted-out hospital to correct the under-staffing of the casualty department, the method of documentation of patient notes, and to carry out an inquiry.
A spokeswoman for the Greenwich Healthcare Trust, which runs Greenwich District Hospital, later promised Sir Montague's recommendations would be carried out in full. But Nick Raynsford, Labour MP for Greenwich, said an independent inquiry should investigate the management of the entire trust.
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