PIONEERING changes have been made to improve patient safety at York Hospital after a man died following a series of errors by staff.

An inquest was told that the hospital’s system “broke and failed” retired university academic John Hatfield after he walked in to A&E on May 1 last year, suffering a gastrointestinal bleed.

Staff failed to prioritise his care properly or carry out observations on him for three hours after he was transferred to an acute medical unit, and he suffered a cardiac arrest eight hours after admission and died several days later.

A staff nurse was sacked and a doctor underwent remedial training after his death, the inquest was told.

Consultant physician Dr Donald Richardson said several things had gone wrong in succession and the 69-year-old patient, from Heworth - who had suffered the original bleed because of Warfarin prescribed for atrial fibrillation, which causes irregular heart rhythm - had paid the price.

“The system broke and the system failed, and it failed John,” Dr Richardson said.

He revealed that a series of changes had since been introduced, including new rotas to meet extra demand in the evening, and computerised systems which helped ensure observations were carried out appropriately and senior staff were called in when needed.

The changes had led to a reduction in patient mortality, and the trust was now assisting others in the region as they sought to make similar changes.

Dr Hatfield’s widow, Madeline, said afterwards: “One person after another made a mistake that shouldn’t have been made.

“He was let down by everybody.

I really do hope this new system works, because we have had the worst 18 months of our lives. I still cry every day.

“There were systems in place and every one of them was broken. All of the protocols were broken.

“He was left to die alone in his bed. If he had been transfused two pints of blood while in the emergency department, my husband could still be alive today.

“He was the heart and soul of the family and we all totally adored him.”

His daughter Katie revealed in her father’s last text to her, he had said: “Don’t worry love, I’ll be all right in here.”

The family are taking legal action against the hospital through specialist medical negligence lawyers Irwin Mitchell.

A spokeswoman for York Teaching Hospital NHS Foundation Trust said yesterday it was sincerely sorry for the circumstances surrounding Dr Hatfield’s death, and had already provided a full apology to his family.

A number of changes had been made to processes within acute medicine following an investigation.

“As demand for our acute services increases we have an even greater responsibility to ensure that our systems and processes are resilient to these pressures and that they fully support our staff in delivering safer care,” she said.

“We have reviewed the rotas to ensure that they better reflect our capacity and demand, and we have also reviewed staffing, including the introduction of Acute Care Practitioners on to the Acute Medical Unit.

“We have also introduced new measures to enable staff to assess and identify those patients that are most at risk.

“These actions have been implemented since the outcome of the Trust’s investigation following Dr Hatfield’s death, and will reduce the risk of another incident of this nature taking place.”