Royal United Hospital patient death: Nurse admits not carrying out proper checks
A nurse at the Royal United Hospital has admitted not carrying out the proper checks before the wrong saline bag was attached to a patient who later died.
An inquest heard that Paul Coventry, from Bradford on Avon, died in February 2011 after a mix-up in the intensive care unit (ICU).
Staff nurse Rosita Chan gave evidence saying she had selected what she thought was a bag of saline solution, but the hearing was told that the one actually put up was a mixture of saline and dextrose sugar.
This meant that 56-year-old Mr Coventry, who had been admitted to the hospital the month before suffering from acute pancreatitis, was mistakenly diagnosed with a high blood sugar level and was given insulin.
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The unnecessary insulin treatment lead to hypoglycaemia and brain damage and accelerated his death.
Ms Chan admitted the usual procedure was to check the content of the saline solution bag and then have it double checked by a colleague, but said she did not do this on the day in question.
However she used her rights under rule 22 of the Coroner’s Rules, which state witnesses do not have to answer questions which could incriminate them, to refuse to talk about the exact moments when the bag was prepared for the patient.
Coroner Maria Voisin also heard that a similar mix-up with saline bags had happened in the ICU in December 2010 and that following that incident, Ms Chan was given specific advice on making sure the proper checks were carried out.
Mr Coventry, who had a history of alcohol abuse, died on February 16, ten days after the bag was attached to his arterial cannula.
Nurse Caroline Liywali, who is employed at a hospital in Stockport but was working agency shifts at the RUH on the night in question, gave evidence about her role in the incident.
She said she had only cared for Mr Coventry for one hour, between 1am and 2am on February 6, while Ms Chan was on a break, and denied that she had set up the bag or that it was her responsibility to check it was the correct solution.
A full police investigation was carried out into Mr Coventry’s death and, after guidance from the Crown Prosecution Service, it was decided there was not enough evidence of who was to blame for it to be a criminal case.
However DC Mike Salter, who is based at Yeovil police station, had some criticism for the procedures in place at the RUH.
He said: “There was an issue with Rosita Chan, her background and how the trust dealt with some of those issues. She had caused concerns and she was at one stage deemed not fit to work in the (nursing) bank, but was then very quickly taken on as a full-time member of staff in ICU.
“There seemed to be a problem, if that is the right word, within HR (human resources), where members of staff who worked in the (nursing) bank could end up with three HR files, but those files never actually all sat in one place... Members of staff were not being assessed on an overall picture, they were being assessed on an incident by incident picture.”
He added: “Clearly there was an incident in December 2010 where Rosita was involved, and it wasn’t until I asked for all the details of incidents that could be deemed to be of a similar nature, that it came to light that actually Rosita was involved in that incident as well.
“That, in my opinion, came as a shock to the hospital because they hadn’t put two and two together.”
The inquest, which is expected to go on until next Tuesday, continues.