A patient of a London hospital suffered liver and kidney damage after her blood samples were left unchecked by a registrar who went on holiday and then signed them off remotely without having seen them.
The medical negligence case has led to changes in policies at The University Hospital Lewisham, with ‘staff reminded of their duty of care to patients.’
The failure to ensure the blood samples were checked meant the patient’s adverse reaction to Atorvastatin – medication she had been prescribed previously following a ‘mini-stroke’ – was not spotted.
Early signs of liver and kidney injuries were also missed.
The patient had attended the outpatient stroke clinic suffering from a range of symptoms including weakness, heartburn, joint pains, fatigue, headache and loss of appetite. She had blood samples taken, the results of which showed ‘red flag’ warnings of the damage being caused.
However, the medical registrar responsible for checking the results failed to do so the following day due to workload demands.
They then went on two weeks’ annual leave without handing over the responsibility, and logged onto the hospital’s system remotely, marking the blood samples as having been reviewed when they hadn’t.
As a result, the patient became increasingly unwell due to her liver function deteriorating, suffering an acute kidney injury.
She was admitted to the hospital again and diagnosed with severe muscle breakdown, requiring dialysis treatment, 22 days after her blood tests had been taken. She was then finally taken off the statins and placed on intravenous fluids.
It was only when attending another appointment at the stroke clinic a further two months later that a consultant checked her records and discovered her blood had never been checked and a ‘serious incident’ was logged.
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The patient took legal action to ensure the matter was fully investigated
The patient, who was 53 at the time and has asked not to be named, said she took legal action to secure hospital negligence claims compensation and ensure the mistake was not ‘swept under the carpet’ and ‘went to the people at the top’. She said:
I love the NHS. It has looked after me all my life from being born at just 26 weeks, and one of my sisters worked in the NHS too, so I thought long and hard about whether I should take legal action.
However, I wanted to make sure that what had happened to me was properly investigated and that it reached the top of the organisation. I didn’t want it to be brushed under the carpet as it had been so dangerous.
My sister said that without making a legal claim my concerns and voice would not be heard, and by taking the route I did there would be a full investigation. It has resulted in changes being made and I am pleased about that.
It really was appalling that my blood were not checked because somebody had gone off on holiday. They took about 8 blood samples from me and then never checked them at all.
I want people to be aware of what statins can do if they have a reaction like I did and are left on them. I was so weak, had no appetite, was full even if I ate a tiny amount and had no energy at all. My sisters said I didn’t realise at the time just how ill I was. They were really worried about me.
I can remember thinking I’ve got too much to live for to die. That in itself shows how worried I was about how ill I’d become.
The claim alleged medical negligence as blood results were signed off without being viewed
A Serious Incident Investigation at Lewisham and Greenwich NHS Trust concluded that the main root cause of the incident was ‘the registrar responsible for checking the results signed off the clinic letter while on annual leave without the results available.’
Legal action was taken against the Trust through our solicitors, alleging that it had amounted to medical negligence.
The Trust, which runs the hospital, admitted liability and breaching its duty of care. It offered a £23,000 out-of-court damages settlement to the patient, who thankfully suffered no long-term harm.
The investigation also identified there had been no formal process in place for one clinician to transfer the responsibility for receiving and acting upon blood test results to another.
It said it was often difficult in such a busy department, and therefore ‘relied on the goodwill of colleagues’.
Following the incident and investigation, the department reduced the clinic workload for medical registrars to ensure they carry out ‘significantly fewer’ clinics, whilst clinic letters are no longer to be signed off remotely unless they also have access to the test results.
Clinical secretaries have also been instructed not to send out letters that do not acknowledge test results.
Expert hospital negligence lawyer Nick Stojanovic, senior clinical negligence solicitor at Hudgell Solicitors, said:
This was a case where a patient was the victim of both human error and failings in systems and processes at the hospital involved.
My client had previously been placed on medication at another hospital following a mini-stroke which would usually be tolerated well, but she had a bad reaction to it causing damage to her liver which should have been spotted in the blood samples.
It was a surprise to learn that the matter had essentially been caused by a member of staff not checking the results and then going on annual leave.
It was also worrying to learn that there was no system in place to transfer the responsibility of reviewing the blood tests to another clinician and that a medical professional misrepresented the facts in stating they had been checked when they hadn’t.
This meant the abnormal test result was not reported and was then later clearly forgotten by the Trust.
It was only when my client’s health deteriorated that this was identified and diagnosed. Fortunately, this was caught quickly enough, but there is no question that this could have had far more serious implications for her health, specifically her kidneys and liver.
In many situations, it can be the case that simple changes in procedures can help prevent similar errors from being made in the future.
We are pleased changes have been made as a result of what happened here and that the Trust dealt with this case swiftly, with a reasonable settlement reached.
I was pleased to be able to get her a good result and see the case make changes to improve services in the future. It is cases like this which continue to motivate me in my work after 20 years in the industry.
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