26.03.2015
Changes Made After Coroner Writes Letter To NHS Trust Demanding Improvements To Systems And Checks
The family of a mother-of-two who died at Sunderland Royal Hospital after failures in prescribing medication to prevent blood clots say they are relieved that the systems are to be improved after a coroner wrote to the NHS Trust responsible to demand changes.
Pensioner Jean James suffered from Alzheimer’s Disease and a lack of mobility due to arthritis and had been a resident at Maple Lodge for months because of her vulnerable condition. In December 2013 the 75-year-old suffered a chest infection which very quickly deteriorated and she was taken to Sunderland Royal Hospital on Christmas Eve.
Over the next few days she was treated with various different medications which seemed to improve her chest but she died on 8 January 2014 due to deep vein thrombosis after the hospital failed to prescribe medication to guard against the risks of blood clots.
Law firm Irwin Mitchell on behalf of Mrs James’ family alleged that staff failed to prescribe treatment to combat the risk of blood clots in her veins. The ‘safety nets’ in place to safeguard this oversight also failed as it was not checked on the first ward rounds and then again during a pharmacy check.
An inquest into her death was critical of her basic care and concluded that she died of “natural causes contributed to by neglect”. Specialist medical negligence lawyers at Irwin Mitchell supported the family at the inquest and will continue to investigate Jean’s care to find out if more could have been done to prevent her death.
A post mortem confirmed that Mrs James had died due to deep vein thrombosis and City Hospitals Sunderland NHS Foundation Trust has now admitted that there were failures in her care and agreed an out-of-court settlement with the family.
Derek Winter, senior coroner for Sunderland, highlighted a number of concerns with Mrs James care including:
- It took too much time to complete Mrs James’ admission details due to the doctor being interrupted approximately five time and this had led to the mistake in not prescribing the appropriate medication
- The omission was not subject to any effective review by a clinician or nurse
- When pharmacy raised a query it was not properly communicated
- The systems that were in place were not sufficiently robust to deal with human errors.
The Trust responded to the Coroner informing him of new systems for identifying patients at risk and that staff across the Trust had been informed of the changes and Mrs James family say they are relieved that changes are being made.
Michelle Armstrong, a specialist medical negligence lawyer at Irwin Mitchell representing Mrs James’ family, said:
At the inquest in March last year the Coroner said that failures were evident throughout Mrs James admission to Sunderland Royal Hospital and that although the employees of the Trust said at the inquest they were taking steps to improve, he remained concerned that the steps may be insufficient.
He wrote to the City Hospitals Sunderland NHS Foundation Trust to demand changes under Regulation 28 of The Coroner’s Investigations Regulations which require the trust to response within 56 days.
Jean’s husband John James, 79, from Sunderland, said: “We were devastated by my wife’s death and are still trying to come to terms with it now. She was rushed to hospital with a chest infection then died less than 10 days later with blood clots in her veins. We couldn’t understand it.
“The inquest was tough to take in because it showed that there could have been more done to treat Jean and we are pleased that the coroner highlighted the seriousness of what had happened.
“Although we have now settled the case with the NHS Trust, this was never about the money, we just wanted the hospital staff to take responsibility for what happened. We are relieved that changes have been made and we just hope that by taking legal action it will ensure that lessons are learned and that others will not suffer from similar failures in future.”
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.
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