Coroner criticises nursing staff after deceased patient had suffered neglect
A coroner has criticised nursing staff for a 'general failing' after an elderly patient went nine hours without an intravenous drip before dying from multi-organ failure with dehydration.
Chesterfield coroner’s court heard on Friday, November 4, at the end of a four-day inquest, how Dorothy Turner, 78, of Foljambe Avenue, Walton, Chesterfield, died at Chesterfield Royal Hospital on September 28, last year, after being a patient on the Emergency Management Unit.
Assistant Derbyshire Coroner James Newman said: “There was a general failing by all nursing staff in that team to complete tasks set out.”
He added: “All nurses could have identified the care plan and the need for an infusion and this was not completed.”
The grandmother and mother-of-three had been re-admitted on September 26, last year, with gastroenteritis and was given a fluid infusion the following day but a Dr Hankinson asked staff nurse Mabel Harris to carry out a further intravenous infusion in the morning of September 28, 2015.
Staff nurse Harris said she had been washing a patient and claimed she told nurse Amie Chapell and thought it would have been done by someone else but nurse Chapell claimed she was not aware of the need for an infusion.
The inquest heard how a care assistant mentioned Mrs Turner had not passed urine and nurse Harris said she asked for a bladder scan about 2.30pm but admitted she had failed to do a fluid check.
She added that when Dr Hankinson further insisted upon an infusion she felt the cannular was not working and confirmed that the infusion did not start until 6pm.
The inquest heard how Mrs Turner’s family had complained during the day about her pain, her difficulty in passing urine and that she was deteriorating and she died at 11.30pm, on September 28, 2015.
Nurse Harris, who was in tears when she discovered the drip had not been set up, said: “The tears were for the fact I omitted to care for the patient properly and it was not my usual stance and I felt I should have done the work and should have abandoned what I was doing. And I should have done it at the time and I was sorry the lady didn’t get the treatment she was prescribed.”
Head of nursing Rachel Whyman said the hospital trust has identified where staff did not do what should have been done and guidance has been outlined.
Assistant Derbyshire Coroner Mr Newman confirmed the cause of death for Dorothy Turner as multi-organ failure with sepsis and acute kidney injury due to hypovolaemia and dehydration, gastroenteritis and hyper-tension.
He said: “Infusion was requested and not set up until nine hours later and there were opportunities to identify that it had not been commenced and documentation should have indicated to an experienced nurse this was the case but it was not completed.”
He concluded Mrs Turner had died from natural causes contributed to by neglect.
One of Mrs Turner’s sons, Stephen Ford, described his mother as an active and vibrant, lady with a wide circle of friends.
He said: “My family were expecting her to come out of hospital after a bout of probable gastroenteritis and to be walking again, going shopping and helping her friends.
“She was a fantastic mum. My sister loved her very much as did her husband of almost 30 years.
“We would have hoped that when she died she would be afforded an element of dignity in the end.”
He added: “Everything suggested an undignified death.”
Mrs Turner’s daughter Rachel Swallow said: “We feel overwhelmed with it all. The outcome of the inquest was the best we could have hoped for in terms of understanding what happened to mum and having some closure. And there is a sense of justice because it established mum was let down.
“For the last year we have re-lived it every night and we wish we could turn the clock back.
“Our aim as a family was to ensure it does not happen to other people.”