Stapleton family speak out about 'mistakes' at Darlington hospital

Mark Ellis was a veteran who served in the army for 25 years and was given a military send-off - but the family day they “haven’t been able to properly grieve” for their dad and husband.

An hour before he died, his daughter Clare Barry visited Darlington Memorial Hospital to drop off home comforts for her elderly father. She was told by two staff members that 73-year-old Mr Ellis would be home soon, and that he was doing well.

But medical records said that Mr Ellis was in the process of dying only 15 minutes after a DNR (do-not-resuscitate) order was signed. He died less than an hour after Clare left the hospital on February 16, 2022.

Following the family filing a complaint, staff at Darlington Memorial Hospital investigated and apologised, acknowledging that “communication had not been up to desired standard”.

The family “can’t understand” how Mr Ellis's state could have declined so quickly. Medical staff had previously told them that he would be coming home, with his wife Barbara Ellis procuring canisters of oxygen and other specialist care tools to look after him.

Now, the Stapleton-based family have spoken out, saying that poor communication and “mistakes” in care - such as missed referrals, delayed scans, and medication - stopped them from saying goodbye to their beloved father and husband and may have contributed to his unexpected death.

Mark Ellis, 73, died in Darlington Memorial Hospital. (Image: Family Handout)

Though Mr Ellis had serious lung conditions, for which he was trying to seek treatment, he lived independently with his wife before his admission to hospital.

In the months before his hospitalisation, Mr Ellis’s healthcare team had wanted to refer him to specialists, but due to an error with his consultant’s email, the referral was never made. Later, a clerical mistake meant appointments were not made for him.

Only when his wife chased them up due to his worsening condition was this revealed.

Mr Ellis was admitted to hospital after struggling to breathe and was found to have a lower respiratory tract infection and tested positive for Covid-19.

Whilst in hospital, Mr Ellis was supposed to have a CT scan and ECG scan, but limited capacity meant scans were delayed.

The day that Mr Ellis died, a “do not attempt resuscitation” order was put on his files, which the family say they were not consulted on. Though his healthcare team judged that CPR would only worsen his situation, the family feels that it should have been “talked about and explained”.

He was also administered two doses of an antipsychotic drug, haloperidol, that the family believes could have exacerbated his deep vein thrombosis.

Following the family’s complaint about the care Mr Ellis received, the Patient Experience team at Darlington Memorial Hospital acknowledged that “communication was not up to the desired standard”.

Mr Ellis’s head nurse and consultant also apologised for not providing updates on his state, and for delays in his referral.

Clare, Mr Ellis’s stepdaughter, said: “It has really affected me, it has really affected all of us. Their apology is alarming and disappointing– it’s not their dad, it’s ours, and they’ll never know what it feels like to lose him.

“It’s just not good enough. It stopped us grieving properly because we have had to fight for everything. We’ve had to fight at every turn."

The ward worked to “introduce appropriate improvements”, and has since reminded staff about “the importance of timely feedback to [patients’] family” following the complaints investigation.

However, the investigation could not conclude that changes in Mr Ellis’s care would have changed his outcome – with his consultant saying that she thinks that it would not have changed the worsening of his condition and subsequent infection with Covid-19.

Using her training as a nurse, Clare has been though all of her father's medical records in the last few months of his life.

She said: “It has really affected me – but it is something I have had to do. We knew that we had to do things even though it has been painful. It’s really not acceptable. 

Mrs Ellis added: “I worry about all the families that don’t have someone with medical training, like Clare, who knows what to look for.

“How many other people had this happened to? How many others have the same story as us?”

A spokesperson for County Durham and Darlington NHS Foundation Trust, said, “We offer our sincere condolences to Mr Ellis’s family and are very sorry they continue to have concerns about aspects of his care. 

“Our patient experience team undertook a thorough investigation of the issues raised by the family through our formal complaints procedure.

“Our response was shared with them in August 2022, however, if they would find it helpful to further discuss their concerns, they can contact our patient experience team on 0800 783 5774.”