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Thursday, 30 October 2014

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Gaps in hospital care contributed to woman's death, inquest told

Gaps in care contributed to the death of an elderly woman at the West Cumberland Hospital in Whitehaven, an inquest has heard.

Dorothy Ross photo
Dorothy Ross

Related: Drug change before dinner lady’s death in hospital - inquest

The details of a serious investigation report were revealed on day two of the inquest into the death of Dorothy Ross, a retired dinner lady.

Mrs Ross, 75, died in hospital on April 18 last year, after falling at her Cleator Moor Road home in Whitehaven the day before, fracturing her left hip and wrist. She was admitted into hospital to await hip surgery.

The inquest heard that prior to surgery, Mrs Ross was taken off the anticoagulant Warfarin – which she was already taking, and was given vitamin K to reverse Warfarin’s affects followed by another blood-thinning drug, Heparin.

However, evidence from a health chief at yesterday’s hearing revealed there were several factors while Mrs Ross was in hospital that resulted in her having a Heparin overdose.

The inquest heard that when delayed blood test results were made available, they showed the high levels of the medication in her system and she was taken off it. Shortly after Mrs Ross suffered a respiratory arrest. She died later that afternoon.

A serious investigation report was carried out after Mrs Ross’ death to find out problems that occurred and to see how the North Cumbria University Hospital Trust, which runs the hospital, could learn from it.

Dr Jeremy Rushmer, chief investigating officer for the trust, highlighted the summary of key findings during yesterday’s hearing.

The report concluded: “Mrs Ross died due to a cascade of interdependent clinical decisions and gaps in care. No nurse or doctors caring for Mrs Ross intended this event to occur but organisational and behavioural factors prevented Mrs Ross from receiving the safe care she deserved.”

The report found: “The decision to use Heparin, including the risks and benefits, and the manner in which it was monitored led to a failure to recognise, in timely fashion, a patient that was over-anticoagulated with both Heparin and Warfarin. This failure, in a patient, who unpredictably had a chronic subdural haematoma, contributed significantly to their risk of acute bleeding, and so to the cause of her unfortunate death.”

It stated: “Organisational failings contributed to this incident, as there were no satisfactory clinical guidelines in place. There were also failures of communication and handover in regard to the medical supervision of a patient with a Heparin infusion and a failure to recognise the significance of the delay in the result of a critical monitoring blood test, with the consequent failure to escalate and act upon its absence.”

The report also found: “The critical lab result was delayed, because within the labs there was no automated system to alert staff delays caused by clinical or technical analyser issues.”

Five recommendations were made to the trust:

To agree to comprehensive clinical anticoagulant guidelines (thirteen aspects were listed for guidelines to be agreed);

The medical team must retain and handover responsibility (at shift change) for safe monitoring of prescribed Heparin;

Changes to laboratory working practice, record keeping and care of patient.

Dr Rushmer told that inquest heard that following Mrs Ross’ death immediate action was taken as patient safety notices and handheld documents were issued. Mrs Ross’ case was also used as an illustration at a patient safety day to raise the profile of issues across the organisation.

A long-term action plan has since been drawn up for the trust and the changes are now being implemented.

Dr Rushmer said: “Everything I intended to put in place has been actioned. We are looking at all of our safety issues in a systematic way.”

The inquest heard that, separately, staffing at the hospital has also been recognised as an issue.

Dr Rushmer said: “A lot of work has been done to improve nurse and staff levels from that time, throughout last year and now.”

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