A woman died after being turned away by three hospitals, including the Royal Sussex County Hospital, in Brighton, because no beds were available.
But a coroner said that she should have been operated on urgently and in the meantime steps taken to work out where she would be cared for after surgery.
Mary Muldowney, 57, suffered bleeding in the brain – a haemorrhage. She would probably have survived if she had been given immediate life-saving surgery to stem the bleeding, coroner Mary Hassell said.
The coroner, Mary Hassell, set out her concerns in a letter to Brighton and Sussex University Hospitals NHS Trust, which runs the Royal Sussex.
The letter was also sent to two other hospital trust chief executives and NHS England boss Simon Stevens.
The coroner said that Ms Muldowney, from Crawley, was admitted to East Surrey Hospital, in Redhill, at about 10am on Wednesday 20 July last year.
A scan found bleeding in her brain and “transfer to a specialist neurosurgical unit was sought as a matter of urgency”.
The coroner said: “The transfer was refused by St George’s Hospital, the Royal Sussex County Hospital, King’s College Hospital and others on the basis that they did not have an available intensive care bed.
“In desperation, knowing of the neurosurgical expertise of a former colleague, one of the East Surrey Hospital doctors went out of area and rang a consultant neurosurgeon at the Royal London Hospital (RLH).
“Invoking the universal acceptance policy, he accepted transfer immediately though the RLH had no intensive care bed available at that time.
“Meanwhile, at about 1pm, Ms Muldowney woke up very briefly while intubated and interacted with her daughter.”
Despite this, her condition was so serious, the coroner said, that “she needed surgery immediately, regardless of whether there was an intensive care bed currently available at the same hospital”.
She added: “Ms Muldowney was transferred to the RLH and taken straight to theatre at 4.40pm.
“Unfortunately, her pupils had become fixed and dilated in the ambulance during transfer to the RLH and surgery did not save her.
“If she had been transferred promptly, it probably would have.
“During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you.
“The matters of concern are as follows. In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.
“She could have been transferred, undergone surgery, spent time in recovery and then an intensive care bed procured, perhaps even by transferring out a non-neurosurgical patient.
“If such a bed was still unavailable, she could then have been transferred to a different hospital, at least having undergone the time-critical clot evacuation and aneurysm clipping.
“With prompt transfer and surgery, Ms Muldowney would probably have survived.
“In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.”
Brighton and Sussex University Hospitals said: “We would like to express our deepest sympathies to Ms Muldowney’s family and friends.
“The trust recognises the importance of responding proactively to requests for assistance from other trusts for the benefit of patients, even when, as in this case, it would normally be another tertiary referral centre to whom such a patient would be transferred.
“We often take neurosurgical patients in emergency situations even if we have no beds available, by utilising appropriate areas elsewhere in the hospital as a temporary measure.
“Unfortunately, at the time of referral, Ms Muldowney was not deemed to require life-saving surgery and therefore there was no indication that emergency transfer was appropriate.”
This is appalling is this what we as a nation have come to in taking care of each other. There are no words I can say that expresses my feelings on this strongly enough. There is a family without a loved one who could still be here but for a bed that SHOULD have been available or at least surgery undertaken and a bed found somewhere but no she was turned away. And why do all these hospitals and organisations always say we would like to express our deepest sympathies like oh sorry and everything is ok now. don’t be sorry sort this mess out as a hospital and a nation. God help us all.
The government should take full blam for this and be made to pay damages
One of the richest nations and we allow this to happen? Where is your leadership Jeremy Hunt? Not to mention your morals
This is totally awful how a hospital can turn away someone so sick I have been to the hospital a few times and the care and treatment is crap terrible really is awful so angry right now !!!!!!!!
But why don’t we have the beds? Because of bed blockers? Because of bed blockers waiting for a package of care? Because we have a longer life expectancy now, and aren’t equipped to deal with this?
And all because of this, patients are needlessly dying.
Clearly this poor dear lady shoulld have been operated on urgently and care found for her, this tragedy is symptomatic of the insideous destruction of nhs and social care services by a system that puts profits before people-a wholly shaocking state of ffairs
This situation is only going to get worse, as the government is in full speed ahead with bringing our NHS to it’s knees. Then they can privitise every bit of it until we are left with a healthcare system like the one in the USA. Money can be found to fund the renewal of Trident but not to train nurses. hmmmmmmm something is awfully wrong with this isn’t it? Blaming the hospital for the lack of a bed is like blaming a child for ripping a hole in his trousers when he was pushed to the ground by the class bully!