Inquest Into Tragic Death Of Woman Who Died From Acute Kidney Failure Following Medication Error

Law Firm Irwin Mitchell To Investigate Failings By The Trust


The distraught family of a woman who suffered from an acute kidney condition after she was given an overdose of a strong antibiotic whilst in hospital has spoken out for the first time following an inquest.

Agnes Power, from Chelmsley Wood died on 31 March 2012 aged 75 in Heartlands Hospital after two weeks of treatment for a chest infection. Her husband Derek Power has instructed specialist medical negligence lawyers at Irwin Mitchell to investigate because of concerns about her care.

An inquest on Tuesday 1 July at Birmingham Coroner’s Court heard that Agnes was admitted to hospital in March 2012 suffering from shortness of breath and a chesty cough. She was prescribed a strong antibiotic called Tobramycin which she was given during her time in hospital. However it has emerged that she was not properly monitored in accordance with the hospital protocol which ultimately led to her suffering from acute kidney failure.

HM Deputy Coroner for Birmingham Mr Saddique recorded a narrative conclusion and said: “Agnes Power died from renal failure due to Tobramycin toxicity as a result of the failure of staff to follow hospital protocol.”

The Heart of England NHS Foundation Trust confirmed they had taken steps to improve staff training to ensure that these fatal errors will not be made again.

The Trust made the following improvements:
• All new doctors from newly qualified to registrar level have specific training on the administration of Tobramycin (it is nephrotoxic drug). This training has been carried out for the past 2 years.
• Rolling training programme introduced for the nursing staff  to enable them to learn about the side effects and administration of Tobramycin. As part of all nurses training when they undergo their training in the administration of intravenous drugs they have to learn about the administration of Tobramycin. It is now part of their competencies.
• The Trust now has one protocol on the hospital system to follow
• Senior consultant cover has been changed at the hospital to ensure that all patients have access to advice from a consultant at least once per day to optimise patient care.

Rebecca Risby, an expert medical lawyer from Irwin Mitchell’s Birmingham office, representing Derek, said: “Agnes’ death was an absolute tragedy and should never have happened. Her death arose after medical staff failed to monitor her kidney function   when she was being given a high dosage of the powerful antibiotic which caused her kidneys to stop working properly.

“Agnes’ family put their trust in the hands of the hospital and on this occasion it would appear from the evidence presented at the inquest that they were badly let down. We will now be investigating further to find out whether more could have been done by the Trust to prevent her death. We are encouraged that the Trust has taken action to improve training for their staff and also to revise the hospital protocol in relation to Tobramycin.

“This case is a stark reminder that one error can have such devastating consequences for patients and their families. Although nothing can make up for the tragic loss of Agnes, they are grateful for the deputy coroner for exploring what happened to help give them some answers as to what went wrong.”

Agnes leaves behind her husband Derek and three children Derek, Elaine and Tania who are devastated by her death.

Derek, 72, said: “Our family has waited two-and-a-half years to finally hear the results of the inquest, and it’s heart-breaking to find out from the Trust about why Agnes died so suddenly.

“It was traumatic for us to see her deteriorate as she did in hospital and I would like to know why more wasn’t done by medical staff to monitor her and adjust the dosage of the antibiotics. My children and I were shell-shocked when she died as she only went into hospital suffering from a chest infection. We have really struggled to come to terms with losing her.

“I hope that with the help of my legal team at Irwin Mitchell that we can finally get some justice in memory of Agnes.

“We were pleased to learn at the inquest hearing that the protocol at the hospital has now been changed and that both medical and nursing staff have been receiving specialist training to ensure that this does not happen again.”

The family are also grateful to Dr Park for being open and straight forward in a meeting immediately after Agnes passed away.

If you or a loved one has suffered as a result of hospital negligence, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.