Failures In Diagnosis

Coroner Rules Serious Failures By Hospital Contributed To Womans Death

Law firm Irwin Mitchell has called for the NHS to make sure it learns from its mistakes after an inquest found that serious failures in diagnosis and treatment contributed to the unexpected death of a Sheffield woman.

Mr Coutts-Wood, Assistant Deputy Coroner for South Yorkshire West, returned a narrative verdict and ruled that although Kathryn Burgin's death was ultimately caused by heart failure, the hospital's failure to diagnose her heart disease and inappropriate use of medication played a part in her death.

Mrs Burgin's family said: "We are satisfied with the conclusion of the inquest. We think that with the correct diagnosis and treatment Kathryn would still be here today, and nothing that has been said at the inquest has made us think otherwise.

"We have lost precious time with a wonderful and caring wife, mother, and nana. As a family this has been a terrible loss and nothing can ever bring her back.

"We only hope that lessons have been learnt and would have appreciated a formal apology."

Kathryn Burgin died aged 70 on 14 April 2009, shortly after being admitted to the Royal Hallamshire Hospital suffering from low blood pressure with a fast and irregular heartbeat.

She was treated with a high dose of Atenolol in order to slow her heart rate, but this caused her blood pressure to drop further.

Although doctors administered glucagon in an attempt to counter the affects of the Atenolol Mrs Burgin died after a series of cardiac arrests, despite several attempts to resuscitate her.

Heather Kolar, Medical Law specialist at Irwin Mitchell, said: "In this case it is clear that the medication Mrs Burgin was given caused her already serious condition to deteriorate further.

"There was a failure to appreciate Mrs Burgin was suffering heart failure on her admission to hospital. The Doctor thought she had a chest infection which was causing her fast heart rate. As a result  she was given a high dose of a Beta Blocker which rapidly lowered her blood pressure. Attempts were made to treat this but, tragically, this was unsuccessful.

"We urge hospital staff to learn from these mistakes to make sure similar cases do not happen in the future."