A&E doctor 'refused' to see woman with asthma attack before she died

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

Marina Young, 46, 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.

Lancashire senior coroner, Dr James Adeley, concluded her death due to an asthma  attack was "preventable". 

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."

The coroner said that a senior doctor then "refused" to see Marina Young for five hours after a senior nurse had asked them to, despite tests revealing her illness was in a "life-threatening category."

He told the hearing that the doctor’s "refusal" to attend was one of several "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, Michelle Young, who had previously worked as a nurse, had written down when she was admitted.

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

Her sister Michelle told the inquest: "I could smell urine. It was so strong it was awful."

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. He told the hearing the form was "little more than a tick box exercise."

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 during the last two years. 

He added: “This is unlikely to be a singular occurrence and there appears to be a risk of other deaths occurring in similar circumstances” and said he said he would make recommendations of how future deaths should be prevented. 

After the inquest, Michelle Young, said hospital staff had "failed her fundamentally on every level. The very basic level of basic human needs, let alone care, was not fulfilled.”