Neglect contributed to death of patient in RUH, decides coroner
An inquest into the case of a patient given the wrong saline solution at the Royal United Hospital has concluded that neglect contributed to his death.
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 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: "The inquest has been long and extremely complex. It has been traumatic for both Mr Coventry's family and our staff who gave evidence.
"First and foremost, we would like to extend our sincere condolences to Mr Coventry's family at this difficult time.
"The inquest was told 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 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.
"The trust will now take into account the coroner's findings and these will guide our decision-making over the next few days."
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. She declined to comment on the verdict.