Burnley grandmother's ambulance fall contributed to death

An inquest into the death of Doreen Pilling, 93, found the fracture left her with very limited mobility in hospital, which contributed to the development of pneumonia from which she did not recover.

Coroner Chris Long, at Preston Coroner’s Court, did not find there had been a gross failure to give basic medical care, but said the method used to move Mrs Pilling by technicians from North West Ambulance Service (NWAS) was not as it should have been and resulted in her sustaining the fracture.

Ms Pilling's daughter, Christine Fitzpatrick, said the conclusion of the hearing was "the right one", and described her mother's suffering and "undignified and distressing death" as "harrowing".

Mr Long also requested a full written explanation from East Lancashire Hospitals NHS Trust as to what is in place regarding the quality and management of quality of nursing charts, with specific reference to Malnutrition Universal Screening Tool (MUST) documentation, fluid balance charts, and medication charts.

He said this should be provided within 28 days and he reserved his right to issue a report if he is not satisfied upon receipt of that letter.

Doreen Pilling (Image: Family)

Mrs Pilling, a retired food technology teacher at Burnley College, lived in her own flat at the Townfields retirement complex in Burnley, and early in the morning on September 3, when trying to lift herself off the toilet, she realised she had no power in her legs.

After waiting for hours to call her family for help, they then called an ambulance, and two technicians arrived at around 9.45am.

One of the technicians asked Christine Fitzpatrick, Mrs Pilling’s daughter, for a towel which was rolled up like a length of rope and used as a makeshift hoist in an attempt to stand her up.

Mrs Fitzpatrick, 65, said as her mother was lifted, the towel rose up her back which caused her legs to buckle and she fell to the floor.

This was disputed by the technicians in evidence, who said Mrs Pilling had been gently lowered to the floor in a controlled manner.

A second ambulance crew arrived to assist and disagreed with the first crew’s plan.

Instead, they used a stretcher and an inflatable pillow to move her onto a full stretcher and into the ambulance.

READ MORE: Family's hope for answers after death of grandmother in 'distressing circumstances'

Technicians Natalie Garner and Andrew Weaver both said the incorrect method had been used. They have since undergone further training.

Further evidence said when Mrs Pilling arrived at Royal Blackburn Hospital, after several hours they were told her leg was not broken but she did have an infection which was why she originally lost power in her legs.

It was not until the morning of September 5 they were told her leg was in fact broken, and it had been left without support since her arrival two days prior.

Mrs Fitzpatrick said nobody seemed to be checking how much food or drink her mother was consuming.

After treatment at Blackburn, including surgery on her leg, Mrs Pilling was moved to Pendle Community Hospital in Nelson on October 6.

Mrs Fitzpatrick said her mother deteriorated rapidly here and could not understand why she was moved. She was moved back to Blackburn on October 14, where they were told Mrs Pilling had pneumonia.

Mrs Pilling continued to be treated at Royal Blackburn until her death at around 8pm on October 24.

Sarah Eastwood, manager of B22 Ward at Royal Blackburn Hospital, giving evidence, said she would expect nursing staff to encourage Mrs Pilling to eat and drink and said: “I apologise if family felt we weren’t assisting enough with diet and fluids.”

Ms Eastwood said Mrs Pilling did receive the care she should have during her stay on the ward and said her pain was managed as it should have been.

She added she expected nursing staff to document everything correctly, but there was no investigation as to whether the charts were accurate in Mrs Pilling’s case.

Ms Eastwood said: “I don’t expect my nurses to incorrectly fill out documentation.”

Concluding the inquest, Mr Long said: “What is very clear in my opinion in relation to the evidence from NWAS is there has been significant training which had now been delivered to them.

“Given the experience of attending this inquest and the questions asked of them with regard to their learning and understanding, I am not concerned that what happened here will reoccur.

“They have learnt a lesson in my view. I cannot and should not issue a report with regard to the steps taken in relation to the ambulance crew.

“It was accepted the technique used to lower Doreen was not as it should have been.

“They accepted the wrong technique had been used. They were honest about that. They were both clear in their evidence about what happened.”

Doreen Pilling (Image: Family)

Offering a narrative conclusion, Mr Long said: “Doreen Pilling died on October 24, 2023, at Royal Blackburn Hospital.

"An ambulance was called to assist Mrs Pilling at her home as she was unable to mobilise.

“She received a fracture of the right distal femur when the crew used an unapproved method to lift her, resulting in an uncontrolled descent to the floor, causing the fracture.

“She was taken to hospital where, after a long stay, she remained unwell with very limited mobility, which contributed to the development of pneumonia from which she did not recover.”

Following the inquest, Mrs Fitzpatrick said: “As a family we are grateful to the coroner for considering my mum’s care so carefully and for reaching this conclusion, which we believe is the right one.

“Watching my mum suffer for so many weeks and die in such an undignified and distressing manner was truly harrowing, and something we will never fully recover from.

“My mum was a lovely lady who gave so much to her family and local community in her life, and she deserved so much better.

“I hope that changes can be put in place to ensure the same poor care is not repeated for another patient in the same situation.”

Madeleine Langmead, a medical negligence solicitor at law firm JMW, said: “I welcome the inquest findings, as they give much-needed answers to Doreen’s family.

"They witnessed her severe decline and the coroner’s conclusion confirms their belief that this was due to the poor care she received.

“However, this is not the end of the road, and we will be investigating the legal avenues available to ensure that there is full accountability.”