They now know Pat should have been put on a sepsis pathway, given nil by mouth and seen 緊急に. Instead she and John waited for a 十分な hour in a 回廊（地帯） in the resuscitation area, not even the 'crammed' main A&E, before she was even triaged.

'They were 急ぐd off their feet, you could see that. One woman beside us in a 車椅子 called her son and said, 'I'm giving up. Come and get me'. She'd been waiting for hours for 血 実験（する）s.'

Every 緊急 患者 is 査定する／（税金などを）課すd によれば the 基準 NEWS 得点する／非難する／２０ (国家の 早期に 警告 得点する／非難する／２０). The paramedics had 得点する／非難する／２０d 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 進歩d through the system. 'And we cannot find out why she was downgraded,' says John.

At about 7pm, 血 実験（する）s were done, but not a 決定的な one called a venous 血 gas 実験（する）, 公式文書，認めるd the 検死官. John 主張するs Pat had an ECG at this 行う／開催する／段階. 'But the paperwork for that has been lost. It was not even 利用できる for the 検死.'

Her 状況／情勢 明確に みなすd not life-脅すing, Pat was taken into a 治療 room, and given tea and water. 'I think they do it to stop people kicking off,' says Paula. 'But in her 事例／患者, it was 悲惨な because there was nowhere for that liquid to go.' At 7.30pm, Pat told John she really needed the 洗面所, but was in no fit 明言する／公表する to get to it. 'I asked for a commode. A nurse said, 'I'll get one', but never （機の）カム 支援する. 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 回廊（地帯） 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 軍の training was 現実に a hindrance here. 'You are trained to stay 静める, not panic, 信用 that the 専門家s around you are doing their 職業s.'

He asked an 整然とした for help, and it （機の）カム, in the form of a 車椅子. He manoeuvred Pat into it and they all made it to the 洗面所 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. 大混乱 everywhere, but I was shouting, ''re you 承認する, Mum?' and she said yes. I said it again and she said yes. The third time, there was nothing.'

The 整然とした opened the door. There, still sitting on the 洗面所, was his mother, dark 事柄 all 負かす／撃墜する her cream 最高の，を越す. 'I thought it was 血, that she had 削減（する） herself, but it was liquid vomit.'

Pat had 苦しむd a cardiac 逮捕（する）. She was unconscious, and only now got help. 'A doctor happened to be passing and it was all 活動／戦闘 駅／配置するs,' says John. 'They got Mum on the 床に打ち倒す and they were doing CPR, and it was good news because this doctor got her breathing again almost すぐに. Someone brought a sheet and a 負担 of us got it under her. I helped them 解除する her on to a 担架.'

Then it was into a 治療 room. 'Not far, but she was on the bed when she 逮捕（する）d again. The room was 十分な of people. I didn't know that someone had gone to get her 医療の 公式文書，認めるs. And this is where it just went so 不正に 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 拷問ing 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 急速な／放蕩な, 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 公式文書，認めるs, had 解除するd the wrong ones.

The 医療の 記録，記録的な／記録するs of a 90-year-old man, who was the 支配する of a do not resuscitate order, were 誤った brought into this already 壊滅的な 状況／情勢.

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

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

Seven months have done little to dissipate the shock, but what is 行方不明の is searing 怒り／怒る directed at an individual.

'I don't 非難する 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 非難する the nurse who made the mistake with the 公式文書，認めるs either. But I do 非難する the system. The most basic checks were not done.

'My mum was 明白に NOT a 90-year-old man. I have asked since if there could not be a special hospital 禁止（する）d given to those who DO have DNR orders 大（公）使館員d. 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 与える／捧げる to Pat's death. 'They said she would have died anyway,' says John. The 検死官 拒絶するd this, and 支配するd it was most probable Pat would have 生き残るd, had CPR been 治めるd, though her long-称する，呼ぶ／期間／用語 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 実験（する）, 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 （機の）カム and said, 'I am so very sorry', and said there would be an 調査.'

This is not one of those 事例／患者s where there is a 長引かせるd 法廷，裁判所 room tussle about failings. The 信用 has apologised and the 検死 findings will 記録，記録的な／記録する, unequivocally, that Pat was let 負かす／撃墜する.

Jawad Husain, (n)役員／(a)執行力のある 医療の director at East Lancashire Hospitals NHS 信用, said they were '感謝する' the 検死官 recognised the difficult circumstances within their 緊急 department at the time but 認める it should never have happened. Mr Husain said: 'This is a 悲劇の 出来事/事件 that should never have happened and for that we are truly sorry.'

And yet as the 検死官 herself pointed out, her remit in 法律 ends at the point where Pat died. Even then, though, her family were 否定するd the care and compassion that they should have received.

In the room where Pat's 団体／死体 was taken, an almost unbelievably farcical 一連の events occurred.

'And this DOES make me angry,' says Paula. 'I'd 急ぐd to the hospital, in utter shock and 設立する John in there sitting with his mum's 団体／死体. There were people waiting in the 回廊（地帯） 権利 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 （機の）カム 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, '井戸／弁護士席, no, but she has just passed away.' She apologised, hadn't realised. She couldn't get out of the room 急速な／放蕩な enough.

'But then there was another knock at the door and another woman popped her 長，率いる 一連の会議、交渉／完成する and said, 'Can I pinch one of your leads?' She 手配中の，お尋ね者 a lead from one of the machines.'

There was a third interruption. Two men （機の）カム in and asked for the 患者's 詳細（に述べる）s. John asked, 'Why?' They replied 'Can we take her 血 圧力?' He said, '井戸／弁護士席, she's dead, so I don't think there is much point'.

'It was just shambolic. How, how, how, can it be so 大混乱／混沌とした that no one knows anything about anything ? and all this in the minutes and hours after they realised that they had made a 抱擁する mistake.'

There was a fourth 侮辱／冷遇, says John. 'There was a doctor in the room when I asked if we could just 攻撃する 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 底（に届く）s 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 いたずら 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 詳細（に述べる） of that evening would need to be 解任するd. 'And I sat and wrote it 負かす／撃墜する,' says John.

How can you have 約束 in the NHS after all that? They 簡単に don't. Paula says that when her brother fell off a ladder and needed to go to A&E she 辞退するd to take him to Blackburn.

'And we had an 承認する experience that time, but 現実に, the problems we are 最高潮の場面ing 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 接触するd us since her death, and even since the 検死, 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 選び出す／独身 nurse or doctor to lose their 職業s over this,' 主張するs John. 'She would say we need more nurses, not より小数の.'