Pensioner inquest criticises hospital

A BREAKDOWN of communication between medical staff led to the death of an elderly patient at one of Suffolk's busiest hospitals, an inquest has heard.Greater Suffolk coroner Dr Peter Dean said there were “severe” failures in the safeguards that should have protected 77-year-old Betty Underwood during her stay at Ipswich Hospital last year.

A BREAKDOWN of communication between medical staff led to the death of an elderly patient at one of Suffolk's busiest hospitals, an inquest has heard.

Greater Suffolk coroner Dr Peter Dean said there were “severe” failures in the safeguards that should have protected 77-year-old Betty Underwood during her stay at Ipswich Hospital last year.

And last night a spokeswoman for the Heath Road hospital said since the pensioner's death there had been a review of procedures in a bid to prevent such a tragedy happening again.

Mrs Underwood of Stoke Park, Ipswich, died of acute haemorrhages to her abdomen, stomach and colon attributed to over anti-coagulation on December 12 after a short stay in Ipswich Hospital.


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She was admitted on December 4 complaining of general ill health and breathlessness and initial tests showed that the pensioner needed medication to thin her blood to prevent clotting and a possible stroke and as a result she was put on a course of antibiotics starting on December 9.

Giving evidence at Ipswich Crown Court yesterday registrar Duncan Massey said it was normal hospital protocol when administrating anti-coagulating drugs to change or maintain the dosage daily according to up to date blood tests but in this instance the procedures were not followed and no further blood test was given until December 11.

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He said that although this test showed Mrs Underwood no longer needed the anti-coagulant the nurses who took the message from the haematology department failed to inform any doctors and the drugs were still administered.

Recording a narrative verdict Dr Dean said there was a clear causal link between the continued administration of the anti-coagulant and the cause of death.

He said: “Mrs Underwood died from a haemorrhage resulting from the administration of excessive anti-coagulant.

“The result of a blood test which indicated the developing problem appeared not to have been communicated or acted upon.

“There were procedures in place for managing potential risks but clearly these were not adhered to. It was protocol to prescribe drugs on a daily basis following blood tests but on two occasions this was not done.

“Unfortunately there were severe failures and nobody on the nursing side seems to have alerted the medical staff to what looks like a grossly abnormal blood result.”

Dr Dean added that he would be writing to Ipswich Hospital to ask them look at all the circumstances surrounding Mrs Underwood's death.

Speaking after the inquest Mrs Underwood's sons David and Gareth said their mother was a lovely lady who would be missed by all.

They continued: “It has been a very thorough inquest, well thought out and precise. We are pleased that the coroner has decided to write to Ipswich Hospital however we are not entirely sure the hospital can live up to the expectations the public have a right to expect.

“Everyone knows what should have been done and it was clear that people were aware of the protocol that should have been followed however unfortunately for our mother it was not.

“It seems that there have already been some changes to the haematology department as a result of an investigation but a breakdown in communication such as this should not have happened.”

A spokeswoman for Ipswich Hospital said since Mrs Underwood's death there had been a thorough review of all procedures.

She added: “We offer our sincere condolences to Mrs Underwood's family following her very sad death which happened almost a year ago.

“At the time we looked very carefully at all of the circumstances and reviewed procedures to make sure all the necessary changes were made.”

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