Missed chances to treat grandmother were ‘neglect’ after she died of heart attack, coroner says
- Credit: courtesy of Tees Law
Missed opportunities to treat a grandmother who died after suffering from a serious blood disorder - including a warning system being ignored 58 times - were equivalent to “neglect”, a coroner has decided.
Karen ‘Jane’ Winn, from Northwold, near Thetford, died at West Suffolk Hospital in Bury St Edmunds, on Monday, April 15, four days after being diagnosed with a suspected urinary tract infection, heard Nigel Parsley, senior coroner for Suffolk.
The 61-year-old was prescribed antibiotics by her GP on April 11, but returned the next day feeling unwell and was referred straight to hospital and admitted the same day.
That evening a senior medical consultant diagnosed Mrs Winn’s condition as haemolytic anaemia, a serious blood disorder, and identified that she was at risk of developing a deep vein thrombosis.
At this point Mrs Winn should have been given a blood transfusion, ‘prednisolone’ steroids, folic acid and anticoagulant medication, the court heard.
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Mrs Winn, wife to Brian Winn, initially received blood transfusions and antibiotics, but steroids and folic acid were not given until April 14, and the anticoagulant was delayed until April 15, but blood clots had already formed during the previous 72 hours.
An automated venous thromboembolism (VTE) risk assessment warning system, embedded into the electronic patient monitoring for all patients, was also manually overridden 58 times between April 12 and 15.
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After Mrs Winn was transferred to the intensive care unit and an hour after her first and only dose of anticoagulant, she suffered a fatal cardiac arrest.
A close family member said: “We are bitterly upset that such an essential part of the treatment available for Jane’s illness wasn’t used promptly.
“The right diagnosis was made, but lifesaving medication was given too late, despite repeated reminders.
“Our hope now is that lessons learned will prevent the same thing happening to anyone else.”
A spokesman for the West Suffolk NHS Foundation Trust said: “We are committed to providing the best quality care to our patients and we extend our deepest sympathies to Mrs Winn’s family.
“We have already changed and strengthened our procedures and safeguards as part of our learning from this very sad case, and are reviewing the coroner’s findings in detail to ensure that any further lessons are learned.”
A post-mortem confirmed that the primary cause of death was a bilateral pulmonary embolism, with deep venous thrombosis and haemolytic anaemia as contributory causes.
The coroner concluded that Mrs Winn’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.
Solicitor Craig Knightley, of Tees Law, acting for the bereaved family, said: “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.”