Inquest into death of woman at Queen’s Hospital highlights BHRUT failings
PUBLISHED: 10:15 05 November 2015 | UPDATED: 11:11 05 November 2015
The son of a woman who died after she was taken to hospital because of the lack of blood flow in her legs has called on the health trust to respond to its failings, which came to light at an inquest into the death.
Senior coroner Nadia Persaud at Walthamstow Coroners’ Court concluded on Friday that Mary Bloom, 89, of Gold Care Nursing Home, Abbey Road, Newbury Park, died of natural causes on February 4 last year at Queen’s Hospital, after being admitted with an acutely ischaemic leg.
Despite the verdict, the coroner’s report highlighted the failings of Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) in the treatment of Mrs Bloom, who lived in Wanstead for 50 years.
The findings revealed staff administered the drug heparin, an anticoagulant which prevents the clotting of blood, to Mrs Bloom, which Ms Persaud said was “appropriate” in preventing further deterioration. But she added: “There was a failure to weigh her before administering the infusion. This was in breach of the trust’s policy.”
Other failings included a failure to consult a haematologist for patients weighing less than 40kg – the coroner said it was “likely” that they would have reduced the dose of heparin.
The coroner found there was a failure to take “post-hydration bloods”, consult next of kin about implementing a Do Not Attempt Resuscitation (DNAR) order and that further monitoring of Mrs Bloom was necessary after a blood pressure drop, which should have led to her being given additional fluids.
Despite the findings, the coroner said: “There was no evidence before me of any significant human intervention which could reasonably have prevented the death.”
Mrs Bloom’s son Bernard said he was disappointed.
“I believe it was an avoidable death,” he said. “To say I’m concerned about the hospital is an understatement.”
BHRUT chief executive Matthew Hopkins said: “The coroner agreed with the independent expert at her inquest that Mrs Bloom’s death was inevitable and unavoidable.”
He said the trust is introducing a tailored IV infusion chart to help with the use of heparin.
“We are also reviewing the information given to staff about how to administer heparin, making sure that the information is clear.”
Mr Bloom is waiting on a new inquest at the High Court into his sister Carmel Bloom’s death. She died after a kidney stone operation at the former Bupa Roding Hospital, Roding Lane South, Redbridge.