Advising with empathy and experience

Woman died after 3 hospitals refused to admit her.

A woman died from a brain haemorrhage after at least three hospitals refused to admit her for surgery because they had no intensive care beds.

Ms Mary Muldowney, 57, was admitted to East Surrey hospital, Redhill, on 20 July 2016 and immediately diagnosed with a suspected bleed on the brain. When a CT scan carried out more than an hour later showed heavy bleeds, doctors requested an immediate transfer to a specialist neurosurgical unit for surgery.

But three units – St George’s Hospital, Tooting, London; Royal Sussex County Hospital, Brighton and King’s College Hospital, London – refused because they had no beds. The coroner heard that other hospitals had been contacted but also had no beds available.

The Royal London hospital (RLH) agreed to take Ms Muldowney but her condition deteriorated in the ambulance and surgery could not save her.

In a letter to bosses at NHS England, inner north London coroner, Mary Hassell, said a consultant neurosurgeon at the RLH, had accepted transfer of Muldowney immediately, “though in fact the RLH had no intensive care bed available at that time.”

She was taken straight to theatre at 4.40pm. But the coroner wrote: “Unfortunately, her pupils had become fixed and dilated in the ambulance during transfer to the RLH and surgery did not save her. If she had been transferred promptly, it probably would have.”

The coroner, who recorded a narrative verdict, said evidence showed that Ms Muldowney “could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured.”

If a bed could not be found she “could then have been transferred to a different hospital, at least having undergone the time-critical clot evacuation and aneurysm clipping.”

She added: “With prompt transfer and surgery, Ms Muldowney would probably have survived. In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.”

Responding, NHS England’s medical director, Sir Bruce Keogh, said Prof Simon Mackenzie, from St George’s hospital, had suggested Ms Muldowney: “was not deemed by the neurosurgical services, to which she was being referred, to require immediate life-saving surgery” and fell outside the scope of the universal acceptance policy.

Sir Bruce wrote: “The process of securing a bed added a delay of just less than two hours to the acceptance process.”