Elderly patient dies after hospital staff fail to give her medication (From Bucks Free Press)

Elderly patient dies after Stoke Mandeville hospital staff fail to give her medication

5:16pm Friday 9th July 2010 in Health By Andy Carswell

Stoke Mandeville Hospital

A HOSPITAL patient died after doctors and nurses failed to give her medication for 36 hours, an inquest heard.

Margaret Brown's condition “deteriorated rapidly” after being admitted to Stoke Mandeville Hospital in the early hours of Saturday January 16.

The “frail” 77-year-old widow, who had a history of heart problems, had to take various medication to keep her heart rate regular and ensure she did not retain too much fluid.

But none of these were ever administered to her, the inquest at the hospital was told.

Coroner Richard Hulett said the efforts by staff to get Mrs Brown's medicine were “haphazard” and “completely lacked the urgency I would expect”.

A post-mortem gave the cause of death as congestive cardiac failure and pulmonary oedema – meaning there was too much fluid in Mrs Brown's body.

Hospital registrar Kiruba Nagaratnam, who was on duty on the following Sunday evening, said Mrs Brown looked “critically ill” when he saw her – only to be told a diuretic drug prescribed for her had not been signed for by a member of staff and therefore not given to her.

Dr Nagaratnam was also told the drugs chart had gone missing from the ward's nursing station.

He said this was the first time he became aware Mrs Brown had not been given any medication, but by then the patient was beyond saving.

He told the inquest: “It became apparent she was about to have a cardiac pulmonary arrest. I knew further resuscitation was unlikely to be successful and would be futile or result in an outcome that was not compatible with life.”

Dr Nagaratnam said: “The medication that wasn't given could have contributed [to her death] but other reasons might be possible. It's a difficult question to answer.”

Maria Bunce, the staff nurse who did the drug round on Sunday morning, said all but one of the drugs on Mrs Brown's chart were unavailable on the ward she had been assigned to. It is normally used for gynaecology patients but due to bed shortages she had been put there.

The only available drug, digoxin – used to treat congestive heart failure – should only be given to patients with a pulse rate of more than 60 beats a minute, Ms Bunce said. But Mrs Brown's pulse rate was 54 beats a minute, so the digoxin was not given to her.

The pharmacy was contacted to see if any more medication was available. Ms Bunce told the inquest the pharmacy only answers phone calls between 10am-12 noon, even though it stays open for longer.

She said someone at the pharmacy called her to say someone would administer the drugs later.

Ms Bunce added: “On that day we were short-staffed. It [the medicine] was harder to chase it up.”

She passed the information on to another staff nurse, Kate Bye, when she reached the end of her shift at 2pm.

But Ms Bye said she was called to deal with a patient in a side room on the ward who was “bleeding heavily”. She said it was not until about 6.30pm she was able to come back onto the ward to treat other patients.

Ms Bye said dealing with Mrs Brown was her next job – but when she went into the treatment room she noticed there were no drug charts for her. She added she could not remember if she spoke to the patient during the course of her shift.

The hospital's security team were called to enter the pharmacy, but this was unsuccessful.

Mrs Brown was originally admitted to Stoke Mandeville after injuring herself, apparently from falling out of an armchair in her sleep at her home in Friars Gardens, Hughenden Valley.

She was given morphine to sedate her while hospital staff took x-rays to see if she had broken her hip, after her daughter Jane Seber said she did not react well to codeine-based drugs.

The x-ray showed no sign of a fracture. Doctors decided to keep Mrs Brown in for observation and rehabilitation before sending her home a few days later.

When she came round from the morphine Mrs Brown was “quite breathless” but otherwise was “bright” and “chatty”.

But the next day she was “more breathless” and “not as bright as before”, her son Kevin told the inquest.

He said his sister was concerned at the fact Mrs Brown was still feeling breathless.

He said: “She wanted to see my mother had been administered her medication. We'd had similar problems before at another hospital, which affected my mother's health.”

Mr Brown said he could not see the sheet listing the drugs his mother needed to take. He was told it had been taken to the hospital's on-site pharmacy earlier in the day, adding nurses had been trying to contact the pharmacy but had not been successful.

At 8.30pm that evening Mr Brown telephoned the hospital to see what was happening, and was told staff were still trying to contact a pharmacist or the doctor who had originally dealt with Mrs Brown when she was admitted.

He was then contacted at about 10.45pm the same evening to be told his mother was seriously ill. Mr Brown arrived at Stoke Mandeville an hour later, but his mother had died already.

Mrs Brown was given all of the medication she needed from a 'dosette box' brought in with her after nurses got permission from a doctor, with the exception of one drug. The inquest heard it is not normal procedure for patients to be given drugs taken from a dosette box container.

Mrs Seber said the drugs prescribed to her mother were a “complex mix” and “seemed to be a balancing act”. All her mother's medication was taken with her when she was taken to the Accident and Emergency department of the hospital by ambulance, she said.

Mrs Brown had an operation to replace a valve in her heart about 13-14 years ago and had been on medication ever since.

Mrs Seber said her mother had gone from “being very active and independent” in 2007 to going “downhill very quickly” in the last 12-18 months of her life.

Summing up the case, Mr Hulett said: “Although you can never say she was definitely well and going home, it wasn't in anyone's contemplation she was at special risk of dying very soon.

“The medication she didn't get in the last 36 hours of her life was the medication prescribed and deemed appropriate by the doctor and registrar.

“The most obvious thing that was different in the last 36 hours was she didn't have the medication. We can't say that would have prevented her death, but it seems ridiculous to ignore the proximity of that failure to administer that medication – and it was a failure – and her death from the very causes the medication was designed to prevent.”

He said: “It seems to me to be a matter of extreme urgency somebody should be pushing the red button and saying 'We have a problem', but that didn't happen.

“Not getting medication in a hospital strikes me as fundamentally unacceptable.”

Mr Hulett recorded a verdict of misadventure.