Royal United Hospital death: Intensive care unit was unusually busy

The intensive care unit (ICU) at Bath’s Royal United Hospital was unusually busy due to a swine flu outbreak when a mix-up contributed to a patient’s death last year.

Yesterday, on the third day today of the inquest into the death of Westwood man Paul Coventry, the court heard that there were not enough nurses on the ward to cope with increased patient numbers.

Margharita Jenkins, a senior staff nurse in the ICU since 2004, said in evidence that former intensive care nurses had been drafted in from other departments, and were given extra training.

But on the night of the mix-up between a saline bag and a saline/dextrose bag, which led to Mr Coventry suffering brain damage as his blood sugar was wrongly calculated and insulin wrongly administered, she said she ‘didn’t have enough nurses for the amount of patients’.

One of the nurses chosen to care for 56-year-old Mr Coventry on February 8 was Jacky Freheit, an experienced intensive care nurse, but on her first day at that unit.

Speaking from the witness box she said the unit seemed very busy when she started and all the beds were full.

She told how she had become concerned about Mr Coventry’s high blood sugar readings that afternoon and, following the advice of Dr Tim Cook and Ms Jenkins, took samples directly from his body rather than the arterial line connected to the saline bag.

When these differed dramatically from the original readings the insulin was stopped, however, she said: “I checked the saline bag three times and what I saw was normal saline.

“On the third check I pulled the mesh of the bag down and could very clearly see it read normal saline with a gap underneath.”

However, when the bag was changed at the next shift it was found to be labelled as saline/dextrose mix, matching the contents.

Junior sister Dorothy Kumar told the court how on the early morning shift on February 7, before Ms Freheit was on duty, she had increased Mr Coventry’s insulin dosage according to procedure after seeing his high blood sugar.

She also claimed to have checked the bag and seen no mention of dextrose.

The court heard evidence again from nurse Rosita Chan, who admitted on Tuesday that she had not carried out the proper double-checking procedure when she selected the saline bag on the night of the mix-up.

She told the court that she had not attached the bag to the patient, she did not know how it had come to be attached, and she could not prove it was the bag later found with the wrong solution inside.

Ms Jenkins, responding to questioning from Mr Coventry’s family’s counsel, Richard Mumford, said she could never tell if Ms Chan had taken on board advice from a performance review carried out in 2010, following an incident in which incorrect drugs were administered.

But, she said she had only come to doubt Ms Chan’s competency in intensive care when she saw the nurse had been on duty when the saline mix-up occurred.

She also confirmed that the saline/dextrose mix is used in paediatric medicine and there should have only been one bag in the unit, on the paediatric trolley. This was later found in its correct place.

The origin of the bag connected to Mr Coventry has yet to be identified, as has the identity of the person who connected it.

The court was adjourned so checks of witness statements could be carried out, after it emerged that one of the circulated witness statements was only a draft copy.

The inquest, at Avon Coroner’s Court, resumes today

Mr Coventry was born and brought up in Bath, where he owned Vincent James car sales firm for many years, becoming well known in the local business community.

He sold the business in 1993 and retired early due to his increasingly poor health.

Mr Coventry moved to Westwood in 2003 to live with his partner Belinda Wells.

She said: “I fell in love with Paul because he was an extremely kind man, a real gentleman, he was always very attentive and looked after me.

“He was also tall and good looking, with his moustache. We thought the same things as each other.

“We were very upset when he died, and we have been waiting a long time for some answers and the truth about how this occurred.

“Paul was very ill, he might not have survived, but they took away his chances.

“What if it had been someone in the prime of his life, or a child, it must not happen again.

“I am relieved that the hospital seems to have changed its policies and I hope they will build on it, and it will go nationwide.

“But the worst thing is that Paul’s death could have been avoided if they had acted when the same thing happened in December.”