Action against nurse after 'neglect' death at RUH
A nurse at the Royal United Hospital has been suspended after an inquest heard that a patient died after being given the wrong saline solution.
Former Bath car dealership owner Paul Coventry, 56, died in February last year from multiple organ failure resulting from pancreatitis and related ailments.
The inquest at Avon Coroner’s Court in Flax Bourton heard how a mix-up which saw a bag of saline solution replaced with a mixture of saline and dextrose sugar hastened his death after it led staff to miscalculate his blood sugar levels.
Mr Coventry suffered brain damage after staff reacted to the dextrose in his blood samples by administering insulin to lower his apparently high blood sugar, leading to hypoglycaemia.
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Coroner Maria Voisin summed up the evidence she had heard before recording a verdict of accidental death contributed to by neglect.
She said she would be writing to both the Department of Health and the RUH with her findings.
Nurse Rosita Chan, who had been a bank nurse before being taken on as a member of staff by the RUH, gave evidence admitting she had not followed the proper procedure of checking the contents of the saline bag, but used her rights under inquest rules to decline to answer some other questions.
Ms Chan has now been suspended by the hospital while it carries out further internal investigations, and the matter is also likely to be be dealt with by the Nursing and Midwivery Council regulatory body.
Ms Voisin said: “There were a number of failures, including wrong fluid being used.
“This contributed to his death as there were inaccurate blood readings, which led to insulin being administered.
“I will be writing to the Department of Health in regards to the wrong fluid being used.
“I will also be writing to the Royal United Hospital to review personnel quality in relation to management of staff, including bank staff.”
During the seven-day inquest Ms Voisin heard evidence from a number of doctors and nurses, including pathologist Dr Russell Delaney, who said the brain damage resulting from the mix-up “hastened” Mr Coventry’s death.
A statement from the RUH said: “A nurse at the Royal United Hospital NHS Trust has today been removed from duty, pending the outcome of an investigation and following the conclusion yesterday of an inquest into a former patient.
“The inquest recorded a verdict of accidental death contributed to by neglect. In her summing up, the coroner said there was conflicting evidence about who assembled the incorrect infusion of fluid prior to it being connected to Mr Coventry.
“The inquest was informed that, following a thorough internal investigation by the trust, a comprehensive action plan to address the failings highlighted by this incident was put in place immediately. The actions include: changing part of the infusion equipment to make the labelling on the fluid bags more visible, having a detailed care checklist for each patient that has to be completed at every shift change and senior nursing staff now cross-check and sign to say that a correct bag of fluid has been selected and put up.
“A similar incident in December 2010 did occur and fortunately on that occasion was detected very quickly and caused no harm to the patient. However the trust still took this matter very seriously and took immediate action to strengthen procedures. We recognize that despite these early actions the mistake sadly repeated itself.”
The statement pointed out that an inquest witness, leading expert in patient safety and intensive care Dr Andrew Hartle, had praised the RUH for the high standards of care he had seen in the intensive care unit where Mr Coventry died.
Mr Coventry’s family were present during the inquest, including his fiancée Belinda Wells, with whom he lived at Lower Westwood, near Bradford on Avon.
Speaking after the inquest, she said she was pleased with the verdict:
“We have waited a long time for this inquest to take place.
“My fiancé Paul Coventry was let down by the standard of care at the RUH at a time when he was at his most vulnerable.
“The coroner conducted a civilised and thorough inquest and in my view reached the correct conclusion.
“It has always been my view that, if the RUH had acted effectively on alerts from similar incidences in other hospitals, prior to Paul’s stay on ITU, he might still be with us.
“I am very determined that no other family or patient will have to endure what we and Paul have been through, because sufficient action was not taken until a death occurred.
“I feel the RUH has learnt a great deal from this tragedy, and it is certainly a safer place to be treated than before Paul died. But we who loved Paul will live with this always, and forever miss him and wonder what might have happened had a different nurse been on duty that night.”