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Woman died after nurses 'forgot' drug during stroke recovery

By Western Daily Press  |  Posted: March 07, 2013

Margaret Churcher

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A woman died after nurses at Bristol Royal Infirmary repeatedly failed to give her a vital drug.

Margaret Churcher was admitted to the hospital after suffering a severe stroke on May 7 last year. But despite her recovering well, nurses on the acute stroke ward failed to give her medication on three occasions to prevent deep vein thrombosis, an inquest heard.

On a fourth occasion a nurse claimed to have given Mrs Churcher the drug but said she had failed to record it. Her husband voiced concerns that his wife’s calf was swollen but it was not mentioned to a doctor until two days later, the coroner was told.

By the time a doctor was aware of the problems Mrs Churcher, of Woodland Road, Nailsea, had developed DVT. Three days later she died after suffering a pulmonary embolism – a blockage of the main artery of the lung by a blood clot – in her room.

The family assumed staff had done all they could for their relative but were told by Dr Peter Murphy he feared there had been multiple errors made in her treatment.

After a three-hour inquest at Flax Bourton Coroner’s Court yesterday coroner Maria Voisin recorded a verdict of death by natural causes, contributed to by neglect.

Mrs Voisin said that in her opinion Mrs Churcher was in a dependant position because of her illness, and the fact nurses did not administer the drug was a “gross failure”.

The family of the mother and grandmother-of-two, who worked as an administrator at a doctors’ surgery, are now considering taking legal action against the hospital.

During the inquest nurses Charlotte Roberts, Marline Ahkon and Kathryn Heyhoe all said they failed to administer Clexane, an anticoagulant drug which had been prescribed by the doctor.

A fourth nurse, Kathleen Tadawan, insisted she had administered the drug but failed to record the fact on Mrs Churcher’s medical chart.

Giving evidence, Miss Ahkon said she was meant to administer the drug on June 5 but wanted to check with a doctor first but forgot. She conceded she had made an “error”.

Nurse Heyhoe was due to give Mrs Churcher the medication on June 6 and also wanted to check with a doctor first. She said: “I got distracted looking after another patient and we were short staffed.” She accepted that not giving the drug was a “failure” on her part.

Miss Roberts told the inquest that it was very busy because June 9 was the Jubilee bank holiday.

Stroke physician Dr Peter Murphy, who had prescribed the Clexane, said: “When I went to see the family they told me they were sure we did everything we could have for her. I told them I was afraid we may not have done everything we could have done and explained that we had potentially missed four doses of Clexane.”

Dr Murphy said he triggered an internal investigation after Mrs Churcher’s death, which has led to increased training and communication between staff.

Alison Moon, chief nurse for University Hospitals Bristol NHS Foundation Trust, which runs the BRI, said: “I and the trust understand what a difficult time this is for Mrs Churcher’s family and our thoughts and condolences are with them.

“It is essential that we change practice when things go wrong and, since Mrs Churcher was a patient at the BRI last year, we have made significant changes.”

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  • siarad2  |  March 07 2013, 10:45AM

    With all these computers around hospitals how can anyone 'forget' My PC reminds me of all manner of things, I've seen on TV tablet PC being carried around too. Are hospital PC only used to show admin. targets & waiting times? Aren't patient care targets