Inquest of Dorothy Ross - Post Inquest Statement
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HM Coroner Mr David Roberts has returned a narrative verdict at the inquest into the death of Mrs Dorothy Ross, a retired dinner-lady from Whitehaven who died at the West Cumberland Hospital, aged 75, on 18th April 2013.
Following the verdict, her son Mr Ian Ross (46) and daughter Ms Gillian Mudie (42) issued the following statement: “When Mam went in to hospital, we assumed she was in a safe place. Our faith and confidence in the health service has been shattered by what we now know. Prior to the inquest, the Trust admitted liability for her death. We were horrified to find out that her treatment at West Cumberland Hospital caused her death. However, the inquest has answered a lot of unanswered questions we had concerning the events leading up to her death.”
“We have had to cope with the devastating consequences of losing our fit, active and independent Mam, but there seem to be no consequences for the hospital staff who made the catalogue of errors which ultimately led to her death. There were a number of opportunities to save her, but all were missed – it was a catastrophic failing which cost us our mother, but we have yet to see any individual at West Cumberland Hospital being held accountable. It doesn’t feel like the hospital is really getting to the root cause of the failings.”
“Our Mam was a staunch supporter of the West Cumberland Hospital, but the people she put her faith in failed her. We don’t want to see the hospital closed, but our community should be able to rely on a safe health service.
We would like to thank our legal team Lynne Hall at Burnetts and Evelyn Pollock of Hailsham Chambers for helping us with this process which has been very important to us to get the truth of what happened to Mam. We also would like to thank David Roberts, the senior coroner, for his comprehensive approach to the finding of facts and conduct of the inquest.”
Because of the circumstances surrounding the death of Mrs Ross, the inquest was held under Article 2 of the European Convention on Human Rights which expands the scope of an inquest to include an investigation into “by what means and in what circumstances” a death occurred.
The family’s solicitor is Mrs Lynne Hall from the medical law team of Cumbrian law firm Burnetts. Mrs Hall said, “The death of Mrs Ross has had a devastating effect on her family. Ian and Gillian have found the inquest process extremely stressful and the evidence has been very upsetting to hear. The Coroner described Mrs Ross’ time in hospital as comprising a whole sequence of missed opportunities that could have prevented her death. In his narrative conclusion he highlighted the failure to clearly document the plan to bridge her with Heparin after reversal of the effects of Warfarin with the administration of Vitamin K. The confusion that resulted from this meant there was no clarity for the doctors and nurses to work to regarding the bridging therapy and what was meant to happen and when it was to happen. This led to different interpretations by the various doctors that were caring for Mrs Ross and nurses interpreting the plan in their own way, including nurses following an unwritten rule regarding when it was safe to administer heparin only one hour after Vitamin K had been given."
Lynne continued, "A mandatory blood sample should have been taken 6 hours after Heparin was started by 22.30 hours but it was not taken until 01.30 hours on the 18th April. This resulted in a 3 hour delay and, although the blood sample was marked urgent it was processed by the laboratory technicians as a routine sample leading to yet further delay. There were then failures by the lab and no interaction between the lab and the nursing staff to communicate the failure to obtain a result from the sample because of the abnormal first reading from the machine and no-one chasing up the results."
"The coroner was critical that no-one took ownership of Mrs Ross' care as there was a failure in the handover process when the day staff went off duty and the night shift staff came on. He used the expression “she fell between two stools” and “no-one was passing on the baton”. There was a failure to recognise that Mrs Ross was intensively over anti-coagulated and sadly for her family she was badly let down by the hospital."
"A number of changes have been made to improve the use of bridging therapy and improvements are ongoing in relation to the laboratory testing, but Ian and Gillian continue to have concerns about staffing issues at the hospital, particularly at night time, and can only hope that what comes out of their Mam’s death is that no future deaths will occur in light of the new regime and no other family will suffer in the way they have as demonstrated by the organisational failings that occurred in their Mam’s case.”
Dr Evelyn Pollock of Hailsham Chambers acted as the family’s Counsel at the five day inquest.
Mrs Ross had two children and two grandchildren.
Published: Friday 15th August 2014
Categorised: Medical Negligence