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.
The tragedy happened after 57-year-old Mary Muldowney, from Northgate, Crawley, was admitted to East Surrey Hospital in Redhill on July 20 last year.
Doctors suspected a bleed on the brain and requested an immediate transfer to a specialist neurosurgical unit for surgery after a scan showed heavy bleeds.
But three units - St George’s Hospital in Tooting, south London, the Royal Sussex County Hospital in Brighton, and King’s College Hospital in London - refused the request because they had no beds available. Other hospitals also said they did not have an available intensive care bed.
Now a coroner has ruled that Mrs Muldowney would probably have survived if she had been given immediate life-saving surgery to stem the bleeding.
In a letter to NHS health chiefs, inner north London coroner Mary Hassell said: “Transfer to a specialist neurological unit was sought as a matter of urgency.
“However, the transfer was refused by St George’s, Royal Sussex Hospital, King’s College Hospital and others on the basis that they did not have an available intensive care bed.
“In desperation, knowing of the neurosurgical expertise of a former colleague, one of the East Surrey Hospital doctors went out of area and rang a consultant neurosurgeon at the Royal London Hospital.”
He accepted transfer immediately, even though the hospital also had no intensive care bed available at that time.
Meanwhile, at about 1pm, Mrs Muldowney woke up briefly and interacted with her daughter.
The coroner said: “She needed surgery immediately, regardless of whether there was an intensive care bed currently available at the same hospital.
“Mrs Muldowney was transferred to the Royal London Hospital and taken straight to theatre at 4.40pm. 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.”
She added that there was ‘a risk that future deaths will occur unless action is taken.’
In a narrative verdict, the coroner said: “She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient.If such a bed was still unavailable, she could then have been transferred to a different hospital, at least having undergone the time critical clot evacuation and aneurysm clipping.
“With prompt transfer and surgery, Ms Muldowney would probably have survived.”
A spokesman for St George’s Hospital said after the hearing: “We would like to express our deepest sympathies to Ms Muldowney’s family for their loss.
“St George’s neurosurgical department operates a ‘universal acceptance policy’ to accept patients that require emergency specialist support. At the time of referral, Ms Muldowney was not deemed to require life-saving surgery which led to a St George’s clinician directly facilitating her transfer to Royal London Hospital.
“St George’s does not at any time refuse emergency admissions that require specialist care for any reason. When a bed is not immediately available, the patient is still accepted and their care is managed in the emergency department by specialists until a bed is available or they go directly to theatre for life-saving surgery.”
A spokesman for Brighton and Sussex University Hospitals NHS Trust said: “We would like to express our deepest sympathies to Ms Muldowney’s family and friends. The Trust recognises the importance of responding proactively to requests for assistance from other Trusts for the benefit of patients, even when, as in this case, it would normally be another tertiary referral centre to whom such a patient would be transferred.
“We often take neurosurgical patients in emergency situations even if we have no beds available, by utilizing appropriate areas elsewhere in the hospital as a temporary measure. Unfortunately, at the time of referral, Ms Muldowney was not deemed to require life-saving surgery and therefore there was no indication that emergency transfer was appropriate.”
A spokesman for King’s College Hospital NHS Foundation Trust said: “Patient transfers are only accepted when medical specialists have been consulted and it is clinically safe to do so.
“We continue to see high levels of demand for our services and are currently in the process of building a new critical care centre. This will add significant bed capacity to our existing four critical care wards.
“We appreciate how difficult this case was and extend our condolences to Mrs Muldowney’s family.”