Wantage: Family Confronts Hospital After Do-Not-Resuscitate Error Left Great-Grandad Without Immediate CPR
wantage — In a narrow, fluorescent-lit ward, family photographs and a cardigan folded on a chair marked a life that staff now acknowledge was mishandled. Barrie Gilbert, 82, from Canvey, was found unresponsive after suffering a cardiac arrest and did not receive CPR until roughly five minutes after he stopped breathing because staff had “incorrectly presumed” a do not resuscitate order was in place.
How the error unfolded and the family’s account
The delay is set out in a letter the family received from the Mid and South Essex NHS Trust. The letter states nursing staff viewed incorrect patient notes, followed an incorrect escalation process and began resuscitation approximately five minutes after Mr Gilbert stopped breathing. The same letter notes there was a nine-hour gap between observations and that a single dose of antibiotics was not given.
Chris Gilbert, Barrie’s son, who complained about his father’s care, described his reaction in stark terms: “He didn’t receive the right treatment, he didn’t receive CPR when he should have because they mixed up his notes. It was negligence, that’s the only word. ” He added: “He did not deserve to be cast aside, literally forgotten and alone to die at the end of a cold and harsh ward. He was a hero to his eight grandchildren and two great-grandchildren, we are left with the horrific knowledge that he was completely and utterly failed by the staff. No amount of training modules can compensate for what happened, the staff who were on shift that night are not fit for purpose. “
Wantage: What the trust acknowledged and the investigatory steps
The Mid and South Essex NHS Trust has apologised to the family and told them learning will be taken to “prevent this from happening again. ” The trust’s letter to Chris Gilbert acknowledged that an incorrect escalation process was followed because staff had “incorrectly presumed” a do not attempt resuscitation order was in place when it was not. That acknowledgement also referenced the ward matron’s findings about the incorrect patient notes.
The family have been told an inquest has been set to examine the circumstances of Mr Gilbert’s death. The family are exploring legal action in response to his treatment.
Social and human dimensions: the aftermath for relatives and the institutional response
The human cost is immediate and specific in the family’s words: a great-grandfather remembered as a “hero” to children, now a subject of an inquiry and potential legal challenge. The institutional response, an apology paired with a promise to learn, frames the situation as remediable through change to systems and practice. What remains unvarnished in the family’s account is a sense that procedural error — misplaced notes, missed observations, a wrong assumption about a DNR status — translated into life-and-death consequences.
For the family, the nine-hour gap between observations and the missed antibiotic dose compound the single, decisive delay in CPR. For the trust, the acknowledgement of error is a starting point for changes it says will follow. The coming inquest aims to establish the sequence and decisions that led to the delayed resuscitation.
The moment when staff finally began CPR, after the five-minute delay, cannot be undone. It is now the subject of formal review, an apology and the family’s determination to pursue further action.
Back in the small, quiet room where photographs and a cardigan remain, the absence is raw and present. The family will attend the inquest scheduled to examine this failure of care, and they have signalled that they may seek legal recourse. The trust’s apology and pledge of learning provide a measure of institutional response, but for Chris Gilbert and his relatives the question of how an 82-year-old from Canvey was left without immediate resuscitation remains unsettled, and the wound of that night endures with the family.
