A Blackburn man suffered an undignified death on a hospital corridor as the health service struggled to cope with pressures and 'overcrowding', an inquest heard. 

Allan Lishman, who suffered from diabetes, oesophageal cancer and heart disease, was admitted to the hospital on January 6 by his carer after falling and cutting his head.

The inquest, held at Blackburn Town Hall, heard concerns from Mr Lishman's family that he was not seen once by a doctor during his stay and he sat in the corridor of accident and emergency for four hours after his initial assessment in triage.

The 71-year-old, of Taylor Close, died later that day from an infection he obtained from the cut suffered in his fall.

During his time in A&E, his family regularly alerted staff to the fact that his health was deteriorating and that he was struggling to breathe alongside concerns that he was not getting enough oxygen.

A statement from a nurse on duty read out by senior coroner Richard Taylor stated that his observations should have been done hourly and this was not done.

He attempted to escalate it and was told that the hospital was working on it as it struggled with overcrowding.

Dave Simpson, head of nursing at East Lancashire Hospitals NHS Trust, was called as a witness.

He said: “The delays were predominately due to the number of patients coming in and that the department already had."

He added: "He should have had interventions within 10 minutes of going through triage, but he wasn’t seen for four hours by a clinician.

“I want it to be clear that it is not okay. We are not surprised by the things we hear and see, and we are trying to do our best and there are situations where people have not done what they should have done.”

Neil Prater, consultant and medical partner at the Royal Blackburn Hospital, was also called to give evidence.

He said: “The situation is bigger than what is happening in our departments, and it is across the whole NHS."

He added: “If the proper practice had occurred, had he received a medication review, had he received proper reviews he might have still died but he would have died with more dignity.”

Mr Prater also assured the court that new measures have been taken since the incident to avoid a repeat occurrence.

These include introducing a pharmacist in the department and reinforcing with staff the importance of regular observations.

The Lancashire Telegraph revealed earlier this year that an average of 68 patients were left waiting for admission on hospital corridors at the Royal Blackburn Hospital.

A health turnaround programme, known as a ‘recovery board’ was launched in May by the Lancashire and South Cumbria Integrated Care Board which ensured ‘zero corridor days’ for hospitals in Lancashire and South Cumbria.

Mr Taylor concluded that the case showed a clear human error, and that Mr Lishman should have been better cared for but the hospital had taken the necessary steps to improve health care since the incident.

He said: “I often start with the premise that nurses want to nurse, it is in the title of the name that is why they go to work but I had to think the situation in the emergency department must be extremely frustrating for everybody working there.

“There is no dignity in his stay in hospital and for you to watch his decline must have been very distressing indeed and they have every sympathy with that.”

Paying tribute, his daughter Maureen Mansfield said: “He was my best friend, a massive Blackburn Rovers fan who he watched religiously.

“He would do anything for anybody, he wasn’t in the best of health and even though he was diagnosed with terminal cancer he took it in his stride.

“I think if it hadn’t been for the fall and going into hospital he probably would still be here."

She also spoke of her fears of other families suffering similar heartache, despite the measures the trust has put in place. 

Recording a narrative conclusion, the coroner said that Mr Lishman died from an infection following a fall. There was evidence of poor monitoring, observations and medication prior to his death. 

Pete Murphy, Chief Nurse at East Lancashire Hospitals NHS Trust, said he was aware of Mr Lishman’s death and described the circumstances around it as extremely sad and upsetting for the family and everyone involved with his care.

He added: “I want to say how sorry I am that whilst Mr Lishman was clearly unwell, he should have experienced better care from the team here at the trust and these failings caused extra distress in his final hours that could have been avoided.

"The trust fully accepts the findings of the coroner and we have already investigated and put a really robust improvement plan in place. We know this won’t change things for this family, but it will help us to avoid this happening again."