Pensioner who died at Whittington Hospital was victim of “failures”
PUBLISHED: 15:35 17 April 2013
A pensioner recovering from knee replacement surgery fell victim to a number of “failures” in care leading up to her sudden death in the Whittington Hospital.
For eight hours doctors failed to treat 73-year-old Manjula Patel as a medical emergency, despite critical warning signs, an inquest into her death heard this week.
Staff at the hospital in Magdala Avenue, Archway, where the mother-of-four died from cardiac arrest four days after the operation, were also slammed by coroner Dr Shirley Radcliffe for “dumbing down” medical notes.
Delays in treatment meant the Finchley pensioner was left with “critically” low levels of sodium in her blood stream – Hyponatraemia – which triggered the arrest.
Coroner Radcliffe said: “There were things that could have been done that weren’t. We can’t say whether earlier treatment would have changed the outcome, but we can say it would have been a better outcome.”
The court heard how Mrs Patel could have been connected to a saline drip – which boosts sodium levels – at 4am the day she died on June 17 last year. Her sodium level at this point was at a “critical” level, the inquest was told.
But due to two doctors, including one junior who was criticised for not summoning a specialist, delaying blood tests Mrs Patel was not given saline until eight hours later because it was thought she was merely “out of breath” and had a chest infection.
Chris Hargreaves, a consultant in charge of intensive care, told the inquest that because brain swelling is linked to heart failure, getting the patient’s sodium levels up earlier “may have led to a different outcome.”
When asked by the coroner if an eight-hour opportunity had been “lost”, he replied: “Yes, I believe it was.” A Serious Untoward Incident (SUI) investigation was carried out by the hospital which found she should have been treated as a “medical emergency” from 4am.
It emerged that the hospital had no guidelines for dealing with hyponatraemia, despite requests from staff.
The court also heard Mrs Patel’s “severe” case warranted being moved to a high dependency ward rather than remaining in an orthopaedic unit, and that blood samples had not been marked “urgent”.
When doctors changed shifts Mrs Patel’s medical notes simply read: “Say hello to patient” – which Dr Radcliffe branded a “dumbing down” and “unprofessional”.
However, she rejected the family’s claims that Mrs Patel was the victim of “gross failure”, saying she had not been completely neglected by the hospital.
Caroline Cross, counsel for the family, said there was enough evidence to suggest the failures “caused or materially contributed to the death”. She added: “There has been gross failure to provide basic medical care... there were multiple occasions over the final hours of her death to put in place measures that were not taken and there were repeated failures to do so.”
But Dr Radcliffe, rather than recording a verdict of neglect, opted for a narrative verdict because it was not possible to say “on the balance of probabilities” if the failures had “altered the tragic outcome.”
Bindya Thakrar, the family’s lawyer, said: “The family hopes that the trust will take the Coroner’s comments on board and learn from their mistakes by ensuring that they make the necessary and life saving changes to their procedures.”
A Whittington spokesman said: “An internal investigation took place and as a result additional safety nets have been put in place.” These include a “flagging system” which automatically triggers an alert if abnormal test results are detected.
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