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Wednesday, 17 September 2014

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Coroner: Fall woman could have lived if correct treatment given

A woman who died at the West Cumberland Hospital in Whitehaven could have lived if the right treatment had been given, a coroner has ruled.

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Dorothy Ross, 75, might have survived if a blood sample had been taken when it was supposed to be, with medics likely to have spotted the effects of a drug she had been given to stop blood clotting, an inquest was told.

Mrs Ross, of Cleator Moor Road in Whitehaven, lost her life at the hospital after being admitted following a fall at her home.

David Roberts, the north and west Cumbria coroner, said she died “of the consequences of” a blow to the head in the fall – but he added a bleed on the brain was “exacerbated” by the treatment adopted before surgery.

A report in the wake of Mrs Ross’s death highlighted numerous failings by the hospital.

Bosses at the trust running the hospital told the News & Star they had “taken appropriate steps to prevent any such incidents happening again in the future”.

The inquest, held at Cockermouth, was told Mrs Ross, a retired dinner lady slipped on a plastic bag at home on April 17 last year.

She was admitted to the West Cumberland Hospital and found to have fractured both her left hip and left wrist.

Mr Roberts, delivering a narrative verdict at the end of an inquest which lasted five days, said she also banged her head, a small bruise appearing behind her ear shortly before she died.

The inquest heard she denied losing consciousness.

Mrs Ross was taking a drug called Warfarin as an anticoagulant – to help prevent the formation of blood clots – and the effects of this had to be reversed before surgery, with the pensioner set to have pins put in.

The plan was to administer vitamin K followed by the drug Heparin, a different anticoagulant, and to check for the level of this drug in her blood after six hours.

But Mr Roberts said: “The recording of the plan was ambiguous.

“Failure to clearly document the plan resulted in premature administration of Heparin,” he said.

Blood for testing should have been taken at 10.30pm of the day she went into hospital but was not taken until three hours later at 1.30am the next morning.

Despite being marked urgent, the sample was processed routinely and a call was not made to the lab stating the urgency. The lab then failed to notify the ward that no analysis had been possible until 7.45am. Nurses had “failed to proactively chase the result overnight”.

A nurse rang for the result at about 9.30am and “the result was off scale”, the inquest heard. The nurse stopped the Heparin infusion but at 9.35am staff could not rouse Mrs Ross and she went into respiratory arrest.

She had developed a subdural haematoma, where the blood collects between the skull and the brain, and died just after 2pm on April 18.

Mr Roberts said it was likely the haematoma was started by the fall and she appeared to have been particularly sensitive to the drug Heparin.

He said that on the balance of probabilities, had a blood sample been taken when due “and reported on promptly” it was likely the effects of the anticoagulant “would have been recognised, the treatment regime altered and that the deceased could have survived”.

Details of a serious investigation report were given earlier in the inquest by Dr Jeremy Rushmer, medical director at the North Cumbria University Hospitals Trust, which runs the West Cumberland Hospital.

The report concluded: “Mrs Ross died due to a cascade of interdependent clinical decisions and gaps in care.

“Organisational failings contributed to this incident, as there were no satisfactory clinical guidelines in place.”

Speaking after the result of the inquest, Dr Rushmer said: “We have recently met with Mrs Ross’s family to offer our sincere condolences and profound apologies for the tragic circumstances surrounding her death last year.

“We have co-operated fully with the coroner’s investigation and carried out our own immediate investigation to ensure we fully embed the important safety learning among all of our teams and across both of our hospital sites.

“While we recognise this does not change the very sad outcome for Mrs Ross and her family, we hope it provides the necessary assurance that we have taken this case extremely seriously and taken appropriate steps to prevent any such incidents happening again in the future.”

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