Our clinical negligence team has settled a claim on behalf of the estate of a woman who died following the negligent failure to provide critical and life-saving treatment during an admission to Bedford Hospital.
Mrs E, a 73-year old woman, suffered from panhypopituitarism and diabetes insipidus (DI). As a result of her condition, she could not recognise when she was thirsty and was unable to regulate her fluid levels. Her DI was well-managed in the community by regularly taking desmopressin and hydrocortisone along with adhering to a strict fluid regime.
Mrs E was admitted to the A&E department at Bedford Hospital on 7 December 2017 where she was initially diagnosed with sepsis of unknown source and then admitted to the Acute Assessment Unit (AAU). During this time, it was noted that she had a history of paranoid schizophrenia and she was therefore deemed to lack capacity. She was sectioned under the Mental Health Act.
On 8 December 2017, Mrs E was transferred from AAU to the Whitbread Ward, but her medication (including the critical drug desmopressin) was not transferred with her. During the course of the weekend, the clinical staff responsible for Mrs E’s care failed to administer the desmopressin for three consecutive days, recording that she was “too drowsy” to receive her oral medication. No efforts were made to administer the medication via an alternative route and as a result, she became hypernatremic from critically elevated sodium levels. Mrs E subsequently suffered a seizure and irreversible brain damage because of severe hypernatremia. She was placed on end of life care and died on 14 December 2017.
An investigation into the cause of Mrs E’s death took place at an inquest at Central Bedfordshire Coroner’s Court over three days in the presence of a jury. The coroner considered that the circumstances giving rise to Mrs E’s death engaged Article 2 of the European Convention of Human Rights (right to life), which widened the scope of his enquiry to consider the broader system failures at Bedford Hospital.
The jury heard oral evidence from the nurses and clinicians involved in Mrs E’s care between 8 and 12 December 2017, including that there was a profound lack of understanding of the critical nature of her medication and the importance of appropriately managing her fluid levels. The jury also heard that intravenous desmopressin was available in the hospital during Mrs E’s admission, but no efforts were made for her administration routes to be modified in light of her deteriorating condition.
The jury concluded that Mrs E died of natural causes aggravated by neglect which arose from a failure to administer lifesaving medication and maintain an appropriate fluid balance.
The coroner closed the investigation and issued a prevention of future deaths report to the chief executive of the trust.
Following the serious incident investigation report prepared by the trust, the defendant admitted liability in full. The trust acknowledged there was a negligent failure to administer critical medications and that this failure diminished Mrs E’s ability to fight the infection from which she was suffering. It also admitted that had she received her medication, she would not have died when she did.
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