Family calls for lasting change after neglect contributed to mother's hospital death

The family of a woman who died while under the care of Doncaster and Bassetlaw Teaching Hospitals Trust is calling for lasting improvements in patient safety following an inquest which found multiple serious failures in her care and concluded that neglect contributed to her death.

Eunice Brookes was admitted to Bassetlaw Hospital in Worksop on 3 September 2025 with severe abdominal pain and vomiting.

Despite her family's repeated concerns, her condition deteriorated before she died on 8 September.

Her daughter, Gail, said: "Mum walked into hospital. Over the next five days we watched her become more and more unwell.

“She was in terrible pain and vomiting we knew something was seriously wrong. We kept raising concerns, but nothing changed."

At the inquest in July 2026, assistant coroner Dr Elizabeth Didcock concluded that neglect contributed to Eunice's death.

She identified serious failures in fluid balance monitoring, pain management, recognising deterioration and obtaining senior medical and surgical review. She also found that despite raising concerns, the family "were not listened to or believed".

The Coroner found that the blockage and twisting of Eunice's hiatus hernia had not been recognised and treated as it should have been, concluding that had this happened, "on balance she would not have died when she did."

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Following the inquest, the Coroner issued a Prevention of Future Deaths (PFD) report to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, raising concerns about her care.

The Coroner described the concerns as "almost identical" to those raised in previous PFD reports issued to the Trust.

Her daughter, Tracey, said: "The Coroner found gross failures to provide basic care and that neglect contributed to her death. It is incredibly difficult for us to understand how this can happen in an NHS hospital. We should have been able to trust that Mum would receive the care she needed.

"Good basic care should never be something patients or families have to fight for. We need to see real, lasting improvements so that other patients don't go through what Mum did."

Since Eunice's death, her family has been working with the Trust to help prevent similar failures in care.

The family has created two digital learning stories, both already being used by the Trust in staff training. One highlights the importance of accurate fluid balance monitoring. The second focuses on listening to patients and families when they raise concerns about deterioration, and why Martha's Rule is so important.

Her daughter, Fiona, said: "Mum could talk for England! So when she stopped talking, we knew something was seriously wrong. We knew Mum, we knew what was normal for her, but staff didn’t react to our concerns or recognise just how significant that change was.”

"We created the videos because we wanted staff to see the person behind the numbers and records and understand that families have valuable knowledge about the people they love. Clinical observations matter, but so does listening to the people who know the patient best."

The family welcomes the discussions and improvements already introduced, including weekday consultant cover on Ward A4, pain management and additional staff education. They remain committed to working with the Trust, while emphasising the importance of continued scrutiny to ensure improvements last.

Her son, Robert, said: "The Trust has made important commitments to improve patient safety and we genuinely want them to succeed. The real test is whether things are actually different for the patient lying in that bed, particularly on a busy ward, at night or over a weekend.”

"We will keep asking questions and working with the Trust, but making sure these changes last cannot be the responsibility of one family. We need the Trust Board, NHS England, the ICBs and regulators to continue asking for evidence that patients are safer – not just now, but in the years ahead."

Dr Nick Mallaband, Chief Medical Officer at Doncaster and Bassetlaw Teaching Hospitals, said: “I am very sorry for the failures in Eunice’s care and the distress caused to her family, whose concerns should have been heard and acted upon. We accept the coroner’s findings.

“Since 2025, we have strengthened consultant cover on Ward A4, improved pain management and provided additional education for colleagues. We are addressing fluid monitoring and the recognition of deterioration, and have put arrangements in place for patients at Bassetlaw Hospital to be assessed on site by the surgical team, 24 hours a day, seven days a week.

“Eunice’s family has made a significant contribution to this work by developing two films sharing their experience, now widely used in training. We are grateful for their support in helping colleagues learn from their experience and understand the importance of listening to patients, relatives and advocates.

“To strengthen this further, we adopted Martha’s Rule this summer, giving patients and families another way to request an independent review if someone’s condition is worsening and their concerns are not being addressed. We remain committed to working closely with Eunice’s family and ensuring these changes deliver measurable, lasting improvements in care.”