Woman died after hospital blunder caused a 'catastrophic' haemorrhage (From Darlington and Stockton Times)
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Ingleby Barwick woman died after hospital blunder caused a 'catastrophic' haemorrhage
A CONSULTANT’S blunder resulted in the death of a woman who suffered a ‘catastrophic’ haemorrhage, an inquest heard.
Iris Alison Pearson had been in James Cook University Hospital for an operation to rectify an aneurism behind her eye and was given the incorrect dosage of an anti-coagulant by Dr Rajeeva Venkataswamy, Teesside Coroner’s Court heard.
Today, (Wednesday) when Assistant Deputy Coroner Sam Faulks gave his narrative verdict, he said the 64-year-old, of Ingleby Barwick, near Stockton, would most likely not have died if the consultant had not miscalculated the dosage.
Her widower, Derek, had called for the coroner to record gross negligence or manslaughter in his findings but Mr Faulks said there was insufficient evidence.
He said: “There is not the evidence before this court, you could be sure that the conduct could be categorised or treated as a crime.”
The court heard that Mrs Pearson’s intravenous drip, to prevent the risk of a blood clot, should have been set at 0.5ml per hour, with a maximum level of 1.1ml, but the consultant set it at 5ml.
And despite the inaccuracy being noticed twice by nursing staff nothing was done until blood tests showed the pensioner had too much of the drug in her system and the machine was switched off.
As a result of the blunder, Mr Faulks said the patient had suffered a catastrophic brain haemorrhage on July, 3, 2010 and died as a result of hospital protocols not being adhered to by the Dr Venkataswamy.
The court heard that new protocols had been put in place to prevent a reoccurrence of the mistake that led to Mrs Person’s death.
He said: “I do not consider that such an error could continue under the system, provided that the new system is operated properly.”
Speaking after the hearing, Professor Rob Wilson, medical director of South Tees Hospitals NHS Foundation Trust, apologised to Mrs Pearson’s family and confirmed that all staff involved remain at the hospital.
He said: “Over the last three years we have carried out our own exhaustive investigation of this very sad situation, as well as fully co-operated with the coroner’s investigation. As a result of those deliberations we have made a number of significant changes to the way our services operate.
“A key change, which was validated by an external expert during the inquest, was improving a trust policy that previously had not provided clinicians with specific advice around what to do if a miscalculation of an anti-coagulant had been made – as in this case. That has been changed and now staff have explicit guidance about what to do in such a situation.
“We are arranging to meet with Mrs Pearson’s family to discuss the coroner’s comments, what action we have taken over the last three years, as well as what we will continue to do to encourage every member of staff to take every opportunity to highlight and rectify issues that may impact on patient care.”
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