Catalogue of errors contributed to Jason Washington's death in St Helier Hospital

Jason Washington, 43, from Carshalton, died after lying undiscovered in a coma for at least 20 minutes outside a toilet entrance in the ward where he had been admitted at St Helier Hospital.

He had been admitted the previous day, October 8, 2010, with breathing difficulties from a chest infection and asthma but a series of errors by staff meant his condition deteriorated unnoticed.

He died of cardiac arrest at the hospital on October 12.

At the inquest into Mr Washington’s death last week, Croydon Coroner Dr Roy Palmer ruled he had died of natural causes contributed to by neglect.

His father, Peter Washington, said: “As far as I’m concerned he should be here now. He should never have died.”

At the inquest Dr Palmer outlined a series of mistakes and poor clinical practice in the hospital’s care, which included staff ignoring doctor’s instructions that a vital test be carried out and failing to notice the unemployed print worker’s condition was deteriorating.

A policy was in place that dictated that acutely-ill patients were only attended to if they asked for help, despite some being so ill that they could not.

One nurse even decided to ignore a doctor’s instruction that Jason be observed every hour and reduced it to every two hours.

The same nurse failed to carry out observations every two hours and took a two-and-a-half hour break, instead of the allotted one hour, leaving Jason and seven acutely-ill patients unattended.

St Helier said changes had been made to prevent such an incident happening again – including carrying out weekly audits of the notes of five patients at a time and staff training on record keeping.  

They have also changed the way they run admissions for acutely-ill patients and increased the number of times they check on patients and the nurse to patient ratio.

Michael Turner, for McMillan Williams Solicitors, acting on behalf of Mr Washington’s family, said it beggared belief this was allowed to happen and that the new auditing system was insufficient and covered too few people.

He said the real problem was nurses chose to ignore their training and reduced the level of care provided to a man who was getting worse.

Jason Washington’s father, Peter Washington, 75, said the past three years had been a nightmare and not only had he lost a son, but the death broke his wife Pam’s heart and she had died too.

Epsom and St Helier Trust’s joint medical director, Dr Martin Stockwell expressed his deepest sympathy to the family and said: “We would like to offer our unreserved apologies to Mr Washington’s family.

“We carried out a thorough investigation into the circumstances of Mr Washington’s death and steps were taken to help prevent something similar ever happening again.”