Our mum was a devoted nurse for three decades, but when she needed the NHS the ... trends now

Retired nurse Pat Dawson had given the NHS 30 years of her life, but had never asked much from it in return. She hadn't been to her GP in three decades, not even when she suspected she had Covid. 'She never wanted to be a drain on resources, because she knew how precious they were,' says her daughter-in-law Paula.

When she did need the NHS last year, aged 73, Pat was full of apologies to the kind and capable paramedics who arrived at her home in Rawtenstall, Lancashire. She was weak and in pain with what they correctly suspected was an abdominal blockage.

Her legs had gone from under her as her son John had tried to get her to his car, and to the hospital himself.

But she was still able to chat to the two-man crew about medical matters – 'how things had changed since her day', says Paula. In the wait to be handed over to A&E staff at the Royal Blackburn Hospital, another kindly paramedic sat with her.

Six hours after Pat's arrival at hospital, John and Paula were walking out, shellshocked.

'By chance, I met the same paramedic who had sat chatting to her,' says John. 'He said, "How's your mum?" When I said, "She's dead", the look of shock on his face... he couldn't believe it. He said, "What happened?" '

What happened, it was confirmed at her inquest this week, was that the NHS had catastrophically failed Pat. She devoted her life to it but when she needed it most, the system collapsed completely.

Thirteen major failings were identified in the care Pat received. She did not see a doctor in her entire time in A&E, despite the paramedics having phoned ahead to alert staff of the seriousness of her condition.

Basic procedures were not followed in the busy A&E department, which had been deemed 'over-capacity and over-stretched' an hour before she arrived. Ninety patients were waiting to be seen, many in corridors.

Nurses were dashing around, 'scribbling names on paper towels', recalls John. 'When we finally got into a room, a doctor would come in and say, to Mum, "Are you Jean? Irene?" before scurrying off again. It was chaos, but you think it must be organised chaos.'

John is ex-military, a former Army corporal, so he doesn't use words such as 'war zone' lightly, but this is how he describes the scene.

'At the very least, if you'd been beamed in from outer space, you'd think there had been a big coach crash or a major incident in that A&E department,' says Paula. 'But it was 9pm on a Tuesday night. It was just an ordinary night. This is what I still can't get my head around. This is normal for the NHS now. How on earth did it come to this?'

The error that led directly to Pat's death in September is almost unthinkable. Having collapsed in a toilet – where she would not have been if a commode had been fetched in time, says John – Pat was given CPR and came round, only to fall unconscious again.

This time, staff simply let her die because in the melee someone else's medical notes – which had a do not resuscitate order on them – were mistaken for hers.

'Mrs Dawson's experience is every patient's worse nightmare,' said Coroner Kate Bisset, sitting at Accrington Town Hall.

'She had diligently served the NHS for 30 years and no doubt believed in everything it stood for. The pressures on emergency departments are well known locally and nationally but in her case a failure to apply first principles and basic care meant her loved ones watched as she died surrounded by doctors with no one helping.'

The Dawson family could have been any of us, but it seems particularly cruel that the system failed Pat.

Today, determined to tell their full story 'because Mum would say this should never happen to anyone again', they fetch a folder found among Pat's things. It contains all her nursing certificates, the letter offering Pat her first job, every award she ever won. 'Look, she was star trainee,' says John, showing me one.

Pat initially worked as a hairdresser, they tell me, but she realised she wanted to retrain when she began cutting patients' hair in a hospital.

'She thought she could make more of a difference that way,' says John. 'She loved the patients. She was hands-on. She worked mostly in a pain clinic, but even after she retired she couldn't give it up because she missed it.

'She went back to work in a local community hub. She only really stopped because my dad got cancer and she needed to nurse him. That all coincided with Covid, and she knew the NHS was under pressure so she did it herself. He died in 2020.'

Pat was a sprightly retiree, rarely poorly, always active. Her grandson Harry, who is eight, was her pride and joy and she had picked him up from school on the Friday before she died.

That night, John and Harry went to hers for 'a chippy tea'. It was a regular treat. The next day, she called John and asked if he could pick up some Dioralyte, a diarrhoea medication.

'She had a dodgy tummy,' he recalls. 'She'd been sick too. Maybe it was something she ate, she said, but it was a little odd because we'd all had the same fish and chips.'

Pat's issues continued over the weekend, and on Tuesday, John found her upstairs, 'half on and half off the bed, obviously in pain, really cold and weak'.

She was still not making a fuss when John called NHS Direct, and described her pain levels as five out of ten. 'Because she was conscious and talking, she wouldn't be an ambulance priority so I could take her to A&E myself. I tried, but getting her down the stairs, she collapsed on me.' He called 999. 'And this time, they said they would send [help] immediately. The paramedics were there within 20 minutes.'

Paula rushed home from work. 'The minute I walked in, I was aware of this smell. The paramedics were asking Pat if she had soiled herself, and she was adamant she hadn't. They told me that it was coming from her breath, which can be a sign of a bowel obstruction – it's faecal matter coming back up through the body, poisoning you.

'I have nothing but praise for the paramedics. They said it was a queried obstruction, and also flagged up "cold sepsis", and they phoned this ahead. Why on earth was this information not acted on? The minute she was passed over into the care of that hospital, it all went so terribly wrong.'

Into the horror of a Tuesday night A&E experience John and his mother went, while Paula stayed at home with their son.

They now know Pat should have been put on a sepsis pathway, given nil by mouth and seen urgently. Instead she and John waited for a full hour in a corridor in the resuscitation area, not even the 'crammed' main A&E, before she was even triaged.

'They were rushed off their feet, you could see that. One woman beside us in a wheelchair called her son and said, "I'm giving up. Come and get me". She'd been waiting for hours for blood tests.'

Every emergency patient is assessed according to the standard NEWS score (National Early Warning Score). The paramedics had scored Pat as a seven out of ten. On admission, however, she was downgraded to a six. She would be downgraded to a three as she progressed through the system. 'And we cannot find out why she was downgraded,'

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