BHRUT 'determined to learn' after inquest finds failures in pensioner's care before her death
- Credit: Chantelle Billson
The trust responsible for Queen's Hospital has vowed to improve after an inquest found "failings" in the care of an Upminster pensioner before she died.
Vivien Brunning died on July 25, 2020 from the effects of a stroke suffered while she was an inpatient at the Romford hospital.
The sequence of events leading to that stroke prompted acting senior coroner Graeme Irvine to conclude that "the role of the Barking, Havering and Redbridge University Trust (BHRUT) was significant".
BHRUT's chief medical officer Magda Smith said BHRUT is "determined to learn" and has made "a number of improvements" since the incident.
Evidence heard at Ms Brunning's inquest - held on October 7 at the Adult College of Barking and Dagenham - revealed Ms Brunning was not given blood thinning medication on two consecutive days.
Mr Irvine said this error had a "causal effect" on the formation of a clot in Ms Brunning's arm.
It was during a procedure to treat this clot that Ms Brunning suffered the stroke which led to her death at age 87.
At the outset, the acting senior coroner defined this inquest as one with "quite a lot of history at this court".
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On July 8, 2020, Ms Brunning was admitted to Queen's Hospital after being found unable to get up in her bathroom.
Treated for a severe urinary infection, it was also found that she had a blocked left kidney due to a kidney stone.
Procedures to treat these went to plan and Ms Brunning began to improve.
However, on the morning of July 15, Ms Brunning told staff that her arm "felt like lead".
Unrelated to the kidney issue, she had not been given her necessary dosage of blood thinner Clexane on either July 13 or 14.
When asked about this error at the inquest, BHRUT's associate director of governance Karen Hunter told the court: "I spoke to both (nurses). They had no recollection of the patient or the incident."
An ultrasound scan revealed a near total block of the brachial artery - the major blood vessel of the upper arm - and doctors decided to undertake a thrombolysis.
It was during this procedure Ms Brunning had the stroke which caused her death 10 days later at Saint Francis Hospice.
When asked, pathologist professor Alan Bate agreed the absence of Clexane would have had "a more than trivial effect upon the formation of a clot".
Ms Brunning death was then referred to the coroner's court on July 27, 2020 by her family.
A post mortem was carried out, the results of which prompted Mr Irvine to open a full investigation into Ms Brunning's death and the inquest was officially opened on December 14, 2020.
When an incident like this occurs, it's customary for an investigation to be launched by the governing trust.
However, it was confirmed that BHRUT did not do this straight away: "It was only after a number of interventions by the court that the trust instigated a serious incident investigation," said Mr Irvine.
A serious incident investigation report has now been completed.
Following the inquest, Ms Smith told the Recorder: “We are sorry Vivien Brunning did not receive the high level of care she was entitled to and our thoughts are with her family.
“Our trust is determined to learn when we don’t get things right and we have made a number of improvements.
"These include appointing a senior harm free care nurse, introducing new education modules for VTE (venous thromboembolism), and strengthening our audit process.”
At the inquest, Mr Irvine explained that coroners have a duty to issue a Prevention of Future Deaths report when matters heard in evidence prompt fears that "a person could die in the future" if procedures aren’t changed.
Acknowledging that there are "some matters of concern" associated with this inquest, Mr Irvine declined to make a final decision on this report.
"I'm going to reflect. It seems to me I've taken in a lot of evidence today."
The acting senior coroner has 10 working days to issue a report.