Harrogate NHS Hospital Trust to 'implement new systems' after death of mum leaves family 'devastated'
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The shocked family of mum-of-three and grandmother-of-five Angela Laybourn from Ripon say they have been “totally devastated” by the loss.
They are calling for lessons to be learned after Harrogate and District NHS Foundation Trust admitted a breach of duty in a legal case.
Harrogate and District NHS Foundation Trust told the Harrogate Advertiser it had offered its sincere condolences and said it was implementing new systems and processes to prevent such incidents from occurring in the future.
Angela Laybourn was admitted to Harrogate General Hospital after suffering from lack of appetite and dehydration for around a week.
Blood tests showed she was suffering from metabolic acidosis – a build-up of acid in the body.
However, this was not documented when she was assessed on a ward, an NHS investigation report found.
Doctors believed Angela, who had a history of kidney stones, had sepsis caused by a water infection.
She was wrongly sent home three days after being admitted.
However, she was readmitted to Harrogate General Hospital two days later.
She was incoherent and disorientated.
Further blood tests indicating metabolic acidosis weren’t acted upon.
She died aged 62 less than two days after her re-admission.
Following Angela’s death, husband David, instructed expert medical negligence lawyers at Irwin Mitchell to investigate his wife’s care under Harrogate and District NHS Foundation Trust.
David, aged 64, has now joined his legal team at Irwin Mitchell in calling for lessons to be learned.
It comes after the Hospital Trust admitted a breach of duty in a legal case brought by Irwin Mitchell.
An inquest into Angela’s death found she died from sepsis – where the body attacks itself in response to an infection – and metabolic acidosis.
A coroner recorded a narrative conclusion ruling that – “the significance of the metabolic acidosis was not recognised or treated as such.”
Megan Walker, the specialist medical negligence lawyer at Irwin Mitchell representing David, said: “Angela was a much-loved wife, mum and grandma, whose death has had a profound effect on all her family.
“Sadly, worrying issues in the care she received, and which contributed to her death, have been identified.
“While nothing can make up for what’s happened it’s now vital that the Hospital Trust learns lessons from the issues in this case to improve patient safety for others.
“We continue to support David and his family at this distressing time.”
Angela grew up in Gosforth, Newcastle and attended Kenton Comprehensive.
Her and David married in 1981.
They had three children, Kristan, aged 38, 35-year-old Graham and Jessica, aged 33, and lived in Newcastle until moving to Ripon in 2011.
Angela was diagnosed with multiple sclerosis in 1999 and within 18 months she paralysed from the neck down.
She had a history of kidney stones.
In December 2021 she underwent surgery to try and remove them
However, doctors were unable to remove all of the stones because of the complexity of the procedure.
Angela started feeling unwell on 10 January, 2022.
Seven days later she was admitted to hospital after she started vomiting.
During her time in hospital Angela’s relatives weren’t allowed to visit her because of Covid-19 restrictions.
She was discharged on 20 January, 2022.
However, Angela’s condition didn’t improve.
She was re-admitted to hospital two days later.
She died in the early hours of 24 January, 2022, after suffering a cardiac arrest.
Her cause of death was sepsis and metabolic acidosis caused by kidney stones.
Following legal submissions by Irwin Mitchell the Hospital Trust admitted that there was a failure to recognise and treat metabolic acidosis following her first admission on January 17.
She shouldn’t have been discharged on 20 January, the Trust acknowledged.
Following her re-admission the Trust didn’t appropriately act upon blood tests indicating metabolic acidosis and there was a failure to treat the condition, it added.
The Trust admitted, that on the balance of probability, with appropriate treatment to correct metabolic acidosis, Angela’s death on 24 January would have been prevented.
An internal investigation report by the Harrogate Hospital Trust into Angela’s care identified a total of 18 key findings, root causes and contributory factors into her care.
These included that blood tests that showed metabolic acidosis following her initial hospital admission were not documented when Angela was assessed on a ward.
Poor communication with Angela’s family was a “major gap”.
They had minimal communication throughout her stays in hospital.
It would have been beneficial for one of them to have been allowed visit and be part of her care given Angela’s needs.
David said: “When Angela as admitted to hospital we hoped she would receive the care she needed.
"However, we weren’t allowed to visit and felt like we couldn’t really contribute to her care.
“Because of her MS, Angela had complex needs.
"No staff asked about her condition or needs.
"Even when I explained I don’t think this was communicated properly to other staff.
“During her first admission myself, Kristan, Graham and Jess would be chasing the hospital as to how Angela was getting on.
"The communication was poor and if we’d not kept phoning, I’m not sure whether we’d have been contacted or given updates.
"This poor communication continued after Angela died and we had to wait months for an explanation in the form of an internal serious investigation as to what had happened.
“I was very concerned about Angela’s condition when she was discharged.
"She seemed incoherent and tired.
“Even after her re-admission it felt like we were facing the same issues as before.”
David, who was Angela’s carer for 15 years, added: “The only way I could describe losing Angela was total devastation.
"As a family, we couldn’t believe that she was really gone. The grandchildren were knocked for six. Angela's whole life was based around her grandkids and kids, everything she did was child orientated. She has been taken from all of us.
“The first time that I was aware that Angela had been suffering from metabolic acidosis, was when we received her death certificate.
"We searched online for the term and were just in complete shock as looking at the symptoms that Angela had they fit the box of metabolic acidosis.
“We just felt let down that no one had picked up on this and that Angela could have been treated for this.
“I miss her all the time.
"The loss of Angela has created an emptiness in my life which will never be filled.
"All I can hope for is that by speaking out improvements in care can be made as I wouldn’t want others to go through the pain our family is.”
Dr Jacqueline Andrews, Executive Medical Director at Harrogate and District NHS Foundation Trust, said: “We would like to offer our sincere condolences to the family and friends of Mrs Laybourn.
"We failed to deliver the level of care Mrs Laybourn and her family should have been able to expect and for this we would like to sincerely apologise.
“We are committed to learning from what has happened and are implementing new systems and processes to reduce the likelihood of important blood test results being missed to ensure we do all we can to prevent such incidents from occurring in the future.”