Croydon great-grandfather dies as family left in dark over end-of-life decision
A family missed the chance to say goodbye to a great-grandfather after doctors placed a "do not resuscitate" notice on his medical records and failed to tell them.
Alzheimer’s sufferer Desmond Dudley, 93, of Sanderstead, died alone in Croydon University Hospital after suffering a heart attack in 2010.
The nurse who found him dying in his hospital bed did not attempt to save him as she knew the notice had been written in his records.
Mr Dudley, a retired sales representative, was admitted to hospital with fractured ribs on March 30 after falling down stairs in his Hyde Road home.
A junior doctor placed the no resuscitation notice on his arrival but did not consult Mr Dudley's family - even though his wife Ellen was present - because he felt "it was not the right time."
NHS guidelines state a patient’s family should be informed within 24 hours of such a decision.
But it was five days after Mr Dudley's admittance that he died - on April 5 - and his family had still not been told.
The decision was later backed by elderly care consultant Dr Prith Navan, who apologised for also failing to tell the family and admitted she had not thought of doing so.
She told an inquest at South London Coroner’s Court on Wednesday that Mr Dudley had chronic underlying heart, lung and kidney disease and would have been unlikely to survive cardiopulmonary resuscitation (CPR.)
Mr Dudley’s Alzheimer’s meant he could not discuss the decision not to resuscitate if he became critically ill, the court heard.
She said: "I am sorry that the opportunity never arose. You can’t just ring someone and ask them out of the blue because all they remember is that their loved one might die."
But she insisted that Mr Dudley’s life could not have been saved by CPR, adding: "The only regret that I have is that we didn’t give the family the time to say goodbye."
The hospital planned to overhaul procedures around 'do not resuscitate' notices, she added.
The inquest was called after Mr Dudley’s family also raised concerns about the hospital's staffing levels after learning he went 36 hours without seeing a doctor in the run-up to his death.
The court heard the hospital had no on-site consultants for four days as it was a bank holiday weekend and that Mr Dudley’s key clinical signs had been monitored by unqualified healthcare assistants.
His family did not learn of his rapidly deteriorating health until after his death.
Caron Heyes, the family’s lawyer, said: "Mr Dudley was a dearly loved father, grandfather and great-grandfather and his family miss him.
"It is so sad that instead of being able to mourn him his family had to endure an inquest, which would never have been needed but for the manner of his care and passing."
Coroner Roy Palmer retired to consider the evidence on Thursday and is expected to return a verdict this month.
The inquest comes ahead of the publication of the findings of a public inquiry into failings at Stafford Hospital, where hundreds of patients died needlessly in an environment staffed with unexperienced doctors and untrained nurses.