A Hospital Trust has admitted being at fault for the death of an elderly patient who suffered a massive blood clot after being left without the vital blood-thinning medication she required for more than two days.
Sheila Brock, 85, was admitted to Hull Royal Infirmary suffering from breathlessness and was given a dose of blood-thinning medicine shortly after her arrival as doctors suspected a pulmonary embolism.
But due to a mix-up over medication records, that was the only medication she was given over the next two days, leading to a massive blood clot developing and causing her to suffer a heart attack.
Following legal representation through Hudgell Solicitors, Hull and East Yorkshire Hospitals NHS Trust has now apologised to Mrs Brock’s family for the errors and agreed a damages settlement.
Patient suffered blood clot and heart-attack just two hours after staff realised mistake
Under a medical plan drawn up by doctors at the hospital, Mrs Brock was due to be given the drug-thinning drug Rivaroxaban at 8am the morning after her admission, along with her usual medication to manage her blood pressure.
However, the nurse responsible for carrying out the drug round was unable to find the medication on the ward at the time, and despite recording it had not been given on a ‘drug card’ – a system to inform ward pharmacists of any medication needs – it was not spotted.
The next morning, when a nurse was again due to give Mrs Brock her Rivaroxaban and the medication was not on the drugs trolley or in ward cupboards, staff realised the issue, and that she’d had no medication since shortly after her admission two days earlier.
Just two hours later, Mrs Brock suffered a heart attack, due to a massive blood clot, and died despite numerous attempts to save her with CPR.
‘She was just another number on the ward, she wasn’t treated as a person’
Mrs Brock’s sister, Sandra, says she will never be able to accept or understand how such a basic error could be made, and cost the life of a patient.
She said: “Our family have always worked in the NHS and have had great trust in the work done to save so many lives. I’ve never really believed media reports criticising hospitals for negligence and saying they are at fault for many deaths, but this has made me think again.
“Sheila had great faith in the NHS, she had twice been in hospital before and was full of praise for the way she was cared for, and for the support given to both her and her husband when he died of cancer.
“She would have had no worries at all about going to hospital, but they let her down massively. It just goes to show that there are some people in the NHS who should not be in their jobs, they don’t care enough about the people. That starts from the bosses in their offices who rarely venture out onto wards to see what is happening.
“There was no care shown to my sister, even though they were dealing with life-saving drugs. She was just another number on the ward, she wasn’t treated as a person and that’s why nobody realised she hadn’t had her medication. It is appalling.
“I can’t simply accept that mistakes happen. How can you accept it when a life is needlessly lost?
Investigation highlighted lack of ‘responsibility and accountability’ of nurses
A Serious Incident Review at Hull Royal Infirmary was unable to clarify why the pharmacist did not see the drug card on the first day, which stated no medication had been given.
It said one possibility was that doctors may have removed the card from the ward’s ‘pharmacy card box’ and not replaced it – as should happen – before the pharmacist carried out their round.
However, it identified there had been no system in place to check if cards had been removed, and that as nurses only focussed on the next medication due, and didn’t look back on previous doses, missing opportunities to spot any mistakes.
It also highlighted that the nurse on the first morning had failed to record the fact no medication had been given on Ms Brock’s own medical notes, whilst the medical team caring for the patient were also not informed.
The Investigation concluded that a ‘system failure’ around the drug cards had allowed a culture to develop where responsibility for dealing with drug issues was passed on to pharmacists by nurses, removing ‘personal responsibility and accountability’.
In a letter to Mrs Brock’s family, who was admitted to Hull Royal Infirmary on November 23, 2015 and died just two days later, Hull and East Yorkshire Hospitals NHS Trust apologised for the errors, and admitted the mistakes had contributed to her death.
No verbal communication over care between nurses, pharmacists and doctors
Solicitor Shauna Page, of Hudgell Solicitors, said: “The facts in this case are truly shocking in that Mrs Brock was left without the life-saving medication she needed for more than two days simply because procedures were not in place to prevent such an oversight happening.
“Nobody was providing enough patient care. No questions were being asked as to whether she’d had her medication and there was no verbal communication between the nursing teams, pharmacists and doctors.
“Effectively, care which made the difference between life and death was left to a card messaging system which failed. In this day and age, it is beyond belief and Hull and East Yorkshire Hospitals NHS Trust have quite rightly made full admissions and apologised.
“Lessons must have been learned as a result of this. Hospitals cannot have systems in place which can so easily go wrong and have such devastating consequences.”
Mrs Brock’s sister added: “We all miss her so much, she was still living a very full life. She lived independently but had found a new partner and they holidayed together three or four times a year, and over Christmas and New Year.
“She also still loved to dance. If she went anywhere and there was a dance floor, you could guarantee she’d be on it. We have great memories of her, but she was taken from us when she had lots of life still to enjoy.”