A retired wife and grandmother tragically died in hospital after multiple opportunities were missed to administer appropriate treatment that could have saved her life, an inquest at the Suffolk Coroner’s Court in Ipswich concluded after a two-day hearing.
HM Senior Coroner for Suffolk, Nigel Parsley, heard that 61-year-old grandmother Karen ‘Jane’ Winn from Northwold near Thetford, Norfolk, died at the West Suffolk Hospital in Bury St Edmunds on Monday 15 April 2019, four days after being diagnosed with a suspected urinary tract infection by her GP.
Jane was prescribed antibiotics by her GP on 11 April, but she returned next day as she was by then very unwell. She was referred straight to hospital and admitted the same day. That evening a senior medical consultant diagnosed Jane’s condition as haemolytic anaemia, a serious blood disorder.
Haemolytic anaemia depletes oxygen-carrying red blood cells and medical staff identified that Jane was at risk of developing a deep vein thrombosis, which can result in a life-threatening pulmonary embolism if a blood clot reaches the lungs. So, correct intervention at that point was vital for Jane.
Once the haemolytic anaemia diagnosis had been made, the immediate response should have involved blood transfusions plus ‘prednisolone’ steroids and folic acid. Anticoagulant medication was intended to be given, subject to the result of a repeat blood test to assess internal bleeding risk.
Anticoagulant delayed
Jane initially received only blood transfusions and antibiotics. Not until 14 April were steroids and folic acid administered, whilst no prophylactic anticoagulant was given until 15 April, by which time it was too little, too late to disperse any blood clots that had formed during the previous 72 hours.
An automated venous thromboembolism (VTE) risk assessment warning system is embedded into the electronic patient monitoring for all patients. Disturbingly, this VTE system was manually overridden 58 times between 12 and 15 April, despite Jane’s increased risk of blood clots.
Sadly, soon after transfer to the intensive care unit and an hour after her first and only dose of anticoagulant, Jane suffered a fatal cardiac arrest. This was the outcome that Jane’s distraught husband Brian and the wider family had feared and one they believe could have been avoided.
“We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly,” says a close family member. “The right diagnosis was made, but life-saving medication was given too late, despite repeated reminders. Our hope now is that lessons learned will prevent the same thing happening to anyone else.”
Significant blood clots
The primary cause of death, a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes, was confirmed at post-mortem. Widespread pulmonary emboli in the lungs and significant blood clots in veins of the upper leg were both evident.
In summary, the Coroner concluded that Jane’s death resulted from the progression of a naturally occurring illness, contributed to by the non-administration of medication to prevent blood clots despite being earlier identified as essential for her treatment; the latter amounted to neglect.
Tees Law, acting for the bereaved family, comments: “A venous thromboembolism risk assessment is mandatory for all patients admitted to hospital and should be completed within hours of admission. It was wholly unacceptable for the assessment alert to have been overridden 58 times over those four days. The Coroner’s finding of neglect acknowledges the total failure to give Jane basic medical treatment that would ultimately have increased her chances of survival.”
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