Our mum was a devoted nurse for three decades, but when she needed the NHS the most, medics let her die because they confused her notes with a 90-year-old man's, which said Do Not Resuscitate

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,' says John.

At about 7pm, blood tests were done, but not a vital one called a venous blood gas test, noted the coroner. John insists Pat had an ECG at this stage. 'But the paperwork for that has been lost. It was not even available for the inquest.'

Her situation clearly deemed not life-threatening, Pat was taken into a treatment room, and given tea and water. 'I think they do it to stop people kicking off,' says Paula. 'But in her case, it was disastrous because there was nowhere for that liquid to go.' At 7.30pm, Pat told John she really needed the toilet, but was in no fit state to get to it. 'I asked for a commode. A nurse said, 'I'll get one', but never came back. When she did, she'd forgotten. I asked again. It must have been an hour later. Mum said, 'I have to'.

'Now, I wonder that if I'd been the type of person to go out into the corridor and shout 'I NEED A COMMODE AND I NEED IT NOW', would she still be alive? But you know they are busy.'

He has lain awake since, wondering if his military training was actually a hindrance here. 'You are trained to stay calm, not panic, trust that the experts around you are doing their jobs.'

He asked an orderly for help, and it came, in the form of a wheelchair. He manoeuvred Pat into it and they all made it to the toilet cubicle. 'And I didn't go in with her, because grown men don't, with their mothers, but again, if I had…' He stood outside, ear to the door. 'It was so noisy. Chaos everywhere, but I was shouting, ''re you OK, Mum?' and she said yes. I said it again and she said yes. The third time, there was nothing.'

The orderly opened the door. There, still sitting on the toilet, was his mother, dark matter all down her cream top. 'I thought it was blood, that she had cut herself, but it was liquid vomit.'

Pat had suffered a cardiac arrest. She was unconscious, and only now got help. 'A doctor happened to be passing and it was all action stations,' says John. 'They got Mum on the floor and they were doing CPR, and it was good news because this doctor got her breathing again almost immediately. Someone brought a sheet and a load of us got it under her. I helped them lift her on to a stretcher.'

Then it was into a treatment room. 'Not far, but she was on the bed when she arrested again. The room was full of people. I didn't know that someone had gone to get her medical notes. And this is where it just went so badly wrong. I was suddenly aware that everyone was just standing there. I remember thinking, 'Come on! Start the CPR again. What are you waiting for?' '

Again he is torturing himself about what he could have done. 'I had basic CPR training myself and I could have gone in there and done it. If I'd known, I would have. But it all happened so fast, and I did not know what had happened.'

What had happened is the worst sort of hospital mistake. A nurse, running to get Pat's notes, had lifted the wrong ones.

The medical records of a 90-year-old man, who was the subject of a do not resuscitate order, were mistakenly brought into this already catastrophic situation.

'It was a matter of moments in that room, but the doctor, who could see on my face that I was obviously thinking 'Why is no one doing anything?', said, 'I'm sorry but I cannot do CPR because there is a DNR in place.'

'Almost immediately after that, she said, 'I'm sorry, your mother has passed away.' '

Seven months have done little to dissipate the shock, but what is missing is searing anger directed at an individual.

'I don't blame the doctor,' says John. 'I'm sure she didn't go to work that morning and think ,'I'll just let someone die'. I don't even blame the nurse who made the mistake with the notes either. But I do blame the system. The most basic checks were not done.

'My mum was obviously NOT a 90-year-old man. I have asked since if there could not be a special hospital band given to those who DO have DNR orders attached. The answer I got was: 'No, because what if we gave the wrong wristband?' It beggars belief.'

The hospital lawyers argued that the mix up, while 'unfortunate', did not contribute to Pat's death. 'They said she would have died anyway,' says John. The coroner rejected this, and ruled it was most probable Pat would have survived, had CPR been administered, though her long-term prognosis would have been uncertain.

What no one will ever be able to tell them is what would have happened had Pat received the care she deserved from the off. 'If she'd had that venous gas test, if she'd had a commode. The 'ifs' just go on for ever,' says John.

Within minutes, the staff realised that they had made a terrible mistake. 'A doctor came and said, 'I am so very sorry', and said there would be an investigation.'

This is not one of those cases where there is a prolonged court room tussle about failings. The trust has apologised and the inquest findings will record, unequivocally, that Pat was let down.

Jawad Husain, executive medical director at East Lancashire Hospitals NHS Trust, said they were 'grateful' the coroner recognised the difficult circumstances within their emergency department at the time but admitted it should never have happened. Mr Husain said: 'This is a tragic incident that should never have happened and for that we are truly sorry.'

And yet as the coroner herself pointed out, her remit in law ends at the point where Pat died. Even then, though, her family were denied the care and compassion that they should have received.

In the room where Pat's body was taken, an almost unbelievably farcical series of events occurred.

'And this DOES make me angry,' says Paula. 'I'd rushed to the hospital, in utter shock and found John in there sitting with his mum's body. There were people waiting in the corridor right outside, you had to almost fight your way through. Inside we sat there, just trying to take in what had happened when there was a knock on the door. A junior doctor came in, all breezy and said, 'Hello! And what brings you to A&E today?'

'Then she looked at Mum in the bed, and said 'Does she always look like this?' John said, 'Well, no, but she has just passed away.' She apologised, hadn't realised. She couldn't get out of the room fast enough.

'But then there was another knock at the door and another woman popped her head round and said, 'Can I pinch one of your leads?' She wanted a lead from one of the machines.'

There was a third interruption. Two men came in and asked for the patient's details. John asked, 'Why?' They replied 'Can we take her blood pressure?' He said, 'Well, she's dead, so I don't think there is much point'.

'It was just shambolic. How, how, how, can it be so chaotic that no one knows anything about anything – and all this in the minutes and hours after they realised that they had made a huge mistake.'

There was a fourth indignity, says John. 'There was a doctor in the room when I asked if we could just tilt the bed up a little. It sounds silly, but she looked uncomfortable. He moved the bed up, but there was something under the mattress – someone else's jogging bottoms and a pair of knickers. The doctor whipped them away, but… what on earth? It was so farcical that I thought, this cannot be real. Someone is playing a prank on us and Jeremy Beadle is going to jump out.'

What would Pat have made of this? 'She would have been horrified, embarrassed, ashamed. Mostly ashamed, I think.'

They left the hospital at midnight, numb, lost, but aware that every detail of that evening would need to be recalled. 'And I sat and wrote it down,' says John.

How can you have faith in the NHS after all that? They simply don't. Paula says that when her brother fell off a ladder and needed to go to A&E she refused to take him to Blackburn.

'And we had an OK experience that time, but actually, the problems we are highlighting here are not unique to this hospital. This is happening in every A&E department in Britain on every night of the week. People have contacted us since her death, and even since the inquest, and everyone has their own horror story. The NHS is failing. It failed her, and it is failing others.'

They have not called for scalps and will not. 'Mum would not want a single nurse or doctor to lose their jobs over this,' insists John. 'She would say we need more nurses, not fewer.'