Expert Medical Lawyers Call For Lessons To Be Learnt Across The NHS

By Helen MacGregor

The heartbroken family of a diabetic woman, whose life could have been saved if medics had carried out a simple blood test, have today echoed lawyer’s calls for lessons to be learnt throughout the NHS to prevent further ‘unnecessary’ deaths.

Margaret Pitt from Redditch, had lived with ‘type one’ diabetes for 30 years, but she suffered an irreversible brain injury and died in November 2010, aged 55, after medical staff at the Alexandra Hospital failed to implement a thorough care plan that would have seen her glucose levels monitored and acted upon accordingly.

Medical law experts at Irwin Mitchell have now secured the mother-of-three’s family an undisclosed settlement and a formal apology from Worcestershire Acute Hospitals NHS Trust, after it admitted failure to check Margaret’s blood glucose on two occasions after she had been admitted to hospital.

The Trust also admitted had these checks taken place, the hypoglycaemia (critically low blood sugar levels) would have been detected sooner and Margaret’s death would have been avoided.

During a five day inquest in June last year, HM Deputy Coroner for Worcestershire, Marguerite Elcock, heard how experienced nurse Sister Jackie Charman failed to carry out blood tests which would have shown that Margaret’s glucose levels were not being controlled after she was admitted. When summarising, the Deputy Coroner described Sister Charman’s actions as a ‘gross failure to provide basic medical treatment’.

A narrative verdict was recorded and Irwin Mitchell lawyers representing the Pitt family referred the case to the Nursing and Midwifery Council (NMC), the authority responsible for nursing standards, to investigate the conduct of those responsible for Margaret’s care.

The watchdog is expected to make a decision on Sister Charman’s fitness to practice in the autumn. A charge of perjury made by the Crown Prosecution Service following the inquest has since been dropped.

Sara Burns, a Partner and medical law expert at Irwin Mitchell’s Birmingham office representing the family, said: “Margaret had lived with diabetes for 30 years, yet the hospital repeatedly missed opportunities to check and stabilise Margaret’s blood sugar to manage her condition. This is totally unacceptable, especially with such a well known condition – patient safety should be the number one priority.

“We were shocked and appalled at the evidence that emerged at the inquest and whilst nothing can bring Margaret back, we hope the admission of liability, settlement and apology provides some justice to her devoted family.

“NHS policies and guides are in place for a reason – to save lives, and staff across the NHS must follow these to prevent unnecessary deaths. We hope that lessons have now been learnt far and wide to protect the safety of other diabetic patients and prevent further unnecessary suffering and the loss of loved ones.”

Margaret was insulin dependent after being diagnosed with type one diabetes when she was 20-years-old and over the years had become used to the daily routine of injections and checking her blood glucose levels.

However, on 4 November 2010, the former teaching assistant began to feel unwell and she recognised the tell-tale signs that her blood glucose levels had risen to a point where she needed medical help. She was admitted to the Alexandra Hospital and after being stabilised in intensive care, she was moved to a ward for ongoing glucose tests and treatment – which sadly were not carried out according to guidelines.

In the early hours of 13 November, Margaret was found collapsed and unconscious and she was rushed back to intensive care where doctors discovered that she had suffered severe brain damage as a result of dangerously low blood glucose levels (hypoglycaemia).

Margaret’s family were told that the damage was irreversible and there was nothing more that could be done. She remained in intensive care until she was transferred to Primrose Hospice on 19 November where she tragically died two days later.

Husband David, 62, a retired credit manager, said: “Maggie and I had been happily married for 35 years and I still can’t get used to life without her.

“The entire family is distraught by her death and it’s hard not to remain angry that she was let down so badly by the nurses that were employed to care for her and make her better.

“Maggie was on a ward which was supposed to have experience of caring for diabetic patients and supposedly had the expertise to treat her condition, yet it appears she was just left to deteriorate without anyone checking her blood sugar levels.

“Whilst the settlement draws a line under the legal action and we are pleased the Trust has admitted wrong-doing, we cannot begin to think about rebuilding our lives until the NMC investigations are complete.

“We just hope Maggie’s death was not completely in vain and that lessons are learnt by trusts across the country so guidelines to protect patients like her will not be ignored again.”

Read more about Irwin Mitchell's expertise relating to medical negligence claims