Hospital admits failings in death of ‘loving’ great-grandmother

Maureen Mayes, a former Snooker Hall manageress who spent most of her life in Sudbury, died at West Suffolk Hospital on March 7, 2021 from a respiratory tract infection.

From the moment she was taken by ambulance to A&E after a fall at her Sudbury home, her son Karl Mayes was sceptical about the quality of care she received.

Ms Mayes went into the hospital with pneumonia but ended up with severe respiratory failure.

Despite protests from the family, the decision was taken not to send the 83-year-old to intensive care. She died nine days after being admitted to hospital.

In April, the hospital told the family it was doing its own review into Ms Mayes’ care. Nine months later in November it was completed and hospital bosses apologised.

But questioning some of the hospital's findings in its review, Mr Mayes has taken the complaint to the Parliamentary and Health Ombudsman, which has agreed to investigate the case.

The review

Mr Mayes, 56, claimed the hospital’s mistakes “never gave mum a fighting chance” — leaving four children, 10 grandchildren, 12 great-grandchildren and one great-great-grandchild without their “loving” ally.

West Suffolk Hospital’s learning from deaths clinical lead Dr Jane Sturgess carried out the initial investigation into Ms Mayes’ death, which was sent to the family in November last year.

The delay was caused by the consultant responsible for Ms Mayes’ care, Dr Ashraf Elawad, leaving the country soon after her death, and not responding to questions about the decisions he made, the hospital said.

“It has been challenging obtaining a response from Dr Elawad”, Dr Sturgess wrote. “But another doctor has provided adequate responses to the concerns raised on his behalf”.

While Mr Mayes said the family had not been able to find out the “whole truth" because of this, Dr Sturgess discovered four important errors regarding Ms Mayes’ care, which the hospital apologised for:

• One of the doctors involved in Ms Mayes’ care “confused” her antibiotics. Ambulance staff were told she was allergic to all antibiotics except Doxycycline, which treats pneumonia, but by the time she got to the hospital this had been recorded as a “Doxycycline allergy”
• Hospital staff had overdosed Ms Mayes on Diazepam (Valium), which left her feeling drowsy and weak
• Staff failed to weigh Ms Mayes on admission and did not complete a weight chart throughout her stay
• Staff did not complete a mental capacity assessment for Ms Mayes, though she was presenting as "confused”

Other findings included in the review which did not result in apologies included:

• The doctors responsible for Ms Mayes’ care ignored a pharmacist’s clinical intervention on March 2 which warned them she was not receiving the correct antibiotics for pneumonia, and only made adjustments on March 5 after her condition deteriorated. The hospital said this was "normal practice"
• Ms Mayes’ respiratory failure could have been picked up earlier if arterial blood gases (ABGs) had been taken at the correct time
• She told staff on multiple occasions she didn’t trust staff and felt she wasn’t receiving good care. Medical records confirm at one point she told staff she “felt she would die” if they didn’t feed her soon

Craig Black, chief executive of the hospital, said staff had identified opportunities to learn following Ms Mayes’ death — particularly around drug safety, the escalation of changes in patients’ vital signs and pressure ulcer care.

He offered his “sincere condolences” to Ms Mayes' family, adding that the care she received was “thoroughly reviewed via the appropriate channels with senior clinicians” and had been “investigated properly”.

"We take all complaints extremely seriously", he said. "We are open and transparent with families around investigations like this and are keen to work with them to understand their concerns."

‘I've done my own research’

But Mr Mayes has spent months scrutinising his mother’s medical records — obtained through a subject access request — against the answers provided by the hospital.

He claims his research has left him doubtful about the hospital’s investigation which is why he has now escalated it to the ombudsman.

The main issue, he said, was that the hospital denied Ms Mayes had sepsis when he asked as part of their internal investigation, claiming there was “no documentation to prove it”.

In Ms Mayes’ medical records, however, it states she was suffering from “sepsis” and “severe sepsis” on four separate occasions.

“How can they not have put this on her death certificate?” Mr Mayes said. “And how can they have missed this in the review? It gives me no faith in them whatsoever.

“I couldn’t have wished for a more loving mother, and now she’s gone because of all of this.”

The hospital said it was not able to respond to specific accusations made by Mr Mayes because it would prejudice the outcome of the ombudsman investigation.

A troubled year

Last year saw the resignation of multiple directors at West Suffolk Hospital, including the chief executive Dr Stephen Dunn, following accusations a whistleblower was "hunted" for sending a letter to a patient's husband about the mistakes involved in her care.

Efforts to track down the person responsible saw staff singled out and pursued for fingerprints and handwriting samples.

In December, a report commissioned by NHS Improvement said hospital management had failed to act on reports an anaesthetist was taking drugs before operating on patients - the same anaesthetist who was the subject of the anonymous letter to Susan Warby's husband after her death.

The hospital apologised, but chairwoman Sheila Childerhouse stepped down and accepted "personal responsibility" for the trust's actions.

This week, controversy has again blighted the trust, with the new interim CEO Craig Black issuing an apology to a victim who was sexually assaulted by another patient at A&E.

Staff were found to have dismissed her accusations, claiming the attack "didn't happen".

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