The family of a woman who hit the headlines as a miracle heart transplant patient and inspired thousands to become potential organ donors say their daughter was let down by hospital staff 11 years after getting her new organ.
Hannah Pudsey, 24, died at Hull Royal Infirmary on February 1 last year after suffering from a condition called metabolic acidosis. Her body was also rejecting her transplanted heart, which she had been fitted with in 2001.
An inquest heard she had been vomiting and complained of chest pains in the days leading up to her death. She was admitted on recommendation of her GP, suspected of suffering a diabetic episode.
Working on Ward 10, a diabetic ward at the hospital, that day were a number of trainee and junior doctors and nurses, one of which was on his first shift.
The inquest heard staff failed to read a letter from Hannah’s GP, which had been handed to hospital staff by Hannah’s mum Ros, detailing her medical history.
Had the letter been opened and read in the hours leading up to her death, Hannah could have been sent to a High Dependency Unit and treated as a complex patient and been made a priority. Instead, the court heard she was left for hours between blood tests.
Dr Suvarna, an independent pathologist who carried out the post mortem examination on Hannah’s body, expressed his concerns that the Trust’s treatment of the diabetic ketoacidosis was prioritised over the heart rejection.
“They should have been treated in tandem and not prioritised over one another,” Dr Suvarna said.
When Hannah was taken to Hull Royal Infirmary from her home in Driffield, East Yorks., she had brought along a letter, written by her mother Ros, which detailed her complex medical history, including details of her heart transplant.
Upon being handed the note, speciality training registrar Dr Kanchan Manchegowda said she failed to read the note. When asked by Coroner Professor Paul Marks if had she read the letter she would have acted on Hannah as a matter of urgency, she replied “Maybe, yes.”
Dr Manchegowda continued: “I didn’t get a chance to look at the information, as I was also dealing with another patient who was also suffering from a cardiac arrest. I was unaware that Hannah had been moved from the A&E department to Ward 10.
“Hannah did not complain about any heart problems to me. She was initially responding to treatment and heading in the right direction.
In a statement read out at the inquest in Hull, Ros said: “Hannah was seen by a junior doctor in the morning and transferred at 12.30pm to a diabetes ward.
“She was not seen by anyone senior on that ward until 4pm. By that time her condition had deteriorated.
“I was concerned that the care she was given was not sufficient. I called a doctor at 6pm when she collapsed and screamed out for oxygen.
“If Hull Royal Infirmary had acted earlier on in the day, maybe Hannah would have survived. We feel she could have survived that day.
“Our family will not find out any more answers. We just want justice for Hannah. The junior doctors did not treat her holistically or as a complex patient.”
Dr Jane Elizabeth Patmore, consultant physician at Hull Royal Infirmary, raised her concerns over her staff’s actions.
“The first decision we made was the wrong one. When staff diagnosed the diabetic ketoacidosis, it was, at best, only part of the issue,” Dr Patmore said.
“If Hannah’s admittance to hospital was purely down to the ketoacidosis, then Ward 10 would have been correct.
“However, my concern is that we set off down a different pathway before we could identify any other issues. Had we identified these, such as the cardiac rejection, we would have taken a different path, and that maybe would have been the High Dependency Unit.”
She confirmed, along with the coroner, that the treatment given to Hannah at the time was correct, despite raising the issue of changing the cause of death to metabolic acidosis.
In a tearful address to the inquest before the Coroner retired to deliver his verdict, Ros Pudsey said: “She was just a wonderful girl who had been through a lot.
“At the end of the day, we weren’t truly listened to, and these people didn’t totally appreciate how knowledgeable we were about our own daughter.
“If Dr Gareth Parry had been there, he would have recognised how ill Hannah was.”
Recording a verdict of natural causes, Professor Paul Marks gave Hannah’s cause of death as metabolic acidosis and cardiac rejection.
“Admittance to the High Dependency Unit and a discussion with a cardiologist may have made a difference to the outcome, but we are unable to say for definite,” Professor Marks said.
“Thus I am persuaded that there have been no missed opportunities which may have changed the outcome.
“I am satisfied that the trust initiated the appropriate measures and that there is no ongoing failure in the system.
“Hannah was a much loved woman who wanted to live a normal life and had succeeded in that.”
Ros said the family received a written apology from Phil Morley, chief executive of Hull and East Yorkshire Hospitals NHS Trust, for “unacceptable mistakes and errors” in Hannah’s death.
Outside court, she said: “I’m obviously a little disappointed with the natural causes verdict as I think it would have been more a narrative verdict,” Ros said.
“In view of Phil Morley’s previous statements to say that he was sorry for the unacceptable mistakes that they made, I do feel we have some closure and we need to move on in our lives and start to try and rebuild it.
“I don’t feel that she was given the best quality care. She was left a long time without further blood tests being ordered, even though they knew earlier in the day that her blood results were not right.
“I was very proud of Hannah. She was absolutely fantastic and she fought for what she believed in. She supported transplantation. It isn’t a cure, but she believed that everyone deserved a chance and she just wanted to live her life everyday to the full.”