A report conducted following the death of a Suffolk woman has outlined a number of areas for improvement.
Susan Warby, 57, from Bury St Edmunds, died at West Suffolk Hospital in August 2018 just over a month after she was admitted with abdominal pain, vomiting and diarrhoea.
An inquest into Mrs Warby’s death took place in September this year during which it was heard that she was given the wrong intravenous fluid for 36 hours which led to insulin being administered incorrectly.
As a result, Mrs Warby developed a brain injury which the inquest heard was of “uncertain severity”.
Senior coroner for Suffolk, Nigel Parsley said the medical cause of death was multi-organ failure and recorded a narrative conclusion which said that the unnecessary insulin treatment “contributed” to her death along with a naturally occurring illness.
In the wake of her death, Mrs Warby’s family received an anonymous letter raising concerns over what happened during her stay at the hospital - prompting the hospital to ask doctors for their fingerprints and handwriting samples in a bid to identify who blew the whistle.
Speaking at her inquest, Mrs Warby’s husband, Jon, said he wanted action to be taken to prevent harm coming to others.
Now, Mr Parsley has outlined his concerns about the case in a prevention of future deaths report which has been sent to the Health Secretary and West Suffolk MP Matt Hancock as well as the Medicines and Healthcare products Regulatory Agency.
Outlining his concerns, Mr Parsley, said that there were a number of areas that needed to be looked at.
This included clearer packaging on the intravenous fluids used by the hospital so that intravenous fluids used are easier to identify by sight.
“It was heard that following Mrs Warby’s death that as far as possible the West Suffolk Hospital has asked its suppliers to change the labelling on the intravenous fluids it purchases,” said Mr Parsley in the report.
“These were exhibited in court and even with the changes the manufacturer was prepared to make, the packaging cannot be considered at all distinctive for fluids to be used in an arterial line.”
Mr Parsley also said that work also needed to be done to ensure that staff were using the correct technique to take blood samples from the arterial line but recognised that improvements had been made.
“As such, the West Suffolk Hospital has already implemented new training and operational regimes for its staff,” said Mr Parsley.
“However, given the apparent prevalence of errors regarding the incorrect use of intravenous fluids and incorrect blood sampling techniques involving arterial lines, a review of training and operational regimes may be considered necessary on a wider basis.”
A spokesman for the West Suffolk NHS Foundation Trust said: “We offer Mrs Warby’s family our deepest sympathies. Aspects of her care could and should have been better and for this we apologise.
“The report recognises that we have put in place enhanced procedures and safeguards to improve the quality of the care we provide, and we have reviewed the coroner’s findings to ensure all lessons that can be learned, are.”
A Department for Health and the Medicines and Healthcare products Regulatory Agency spokesman said: “We are aware of the Report to Prevent Future Deaths, following the inquest into Susan Warby’s death.
“We are currently analysing the report and preparing a response to the coroner.”
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