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Hospital's failure to give essential drugs led to Helston woman's death
4:00pm Thursday 12th September 2013 in News
Failure to give three doses of an essential drug sparked a series of events leading to the death of a Helston patient in the care of the Royal Cornwall Hospital.
Since her death “robust” changes have been made to pharmacy practices at the hospital, an inquest heard last week.
Lynn Ann Smith (née Climo), from Hellis Wartha, died on November 6 last year, shortly after staff failed to administer hormone replacement drugs needed to control the amount of water in the body.
Mrs Smith, 42, had a damaged pituitary gland as a result of brain surgery in 2005 and the tablets controlled an electrolyte imbalance.
The inquest heard Mrs Smith had a complex medical history that began with childhood leukaemia and included a mastectomy, liver cirrhosis and meningioma (a tumour in the brain) up to her death. She was also registered blind and received 24-hour care at home.
She had been taken to hospital for investigations into possible breast cancer – although tests subsequently showed no indication of this.
However, due to a mix up between nurses and the in-hospital pharmacy, Mrs Smith did not receive the hormone replacement therapy for a 24-hour period during her stay. As a result Mrs Smith was left severely dehydrated.
“Vigorous” hydration was carried out, to the extent that Mrs Smith became “fluid overloaded” in the opinion of Dr Nigel Bailey, medical oncologist at the hospital. A post-mortem found fluid on her lungs.
Coroner Dr Emma Carlyon was told that a nurse had filled in the appropriate paper slip ordering the drugs to be sent up to the Lowen ward, placing the slip in the pharmacy order request bag.
However, for an unknown reason – possibly because the slip was missed or got lost – the tablets were never sent up.
The error was not spotted until Dr Bailey carried out his ward rounds a full day after Mrs Smith had her last dose.
Ian Davidson, chief pharmacist at the hospital, said an internal investigation had been carried out into the death. Since then the hospital had installed a £1 million electronic prescription and administration system that was in the process of being trialled.
The drug desmopressin, which Mrs Smith did not receive, had also been added to the hospital’s “critical medicine list” – a list of drugs that were particularly important not to be missed.
Dr Carlyon recorded a verdict of accidental death, ruling out negligence.
She agreed with consultant pathologist Dr Hugh Jones that the cause of death was pulmonary oedema (fluid on the lungs) due to omitted treatment of hypopituitarism (hormone imbalance), with recurrent meningioma and liver cirrhosis as contributory causes.
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