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Coroner slams hospital after woman dies

Jul 18 2007

AN INQUEST has criticised communications at Leighton Hospital after a gravely ill Crewe woman's medical notes were left blank for up to five days before she died.

Elizabeth Dodd, 67, died on February 9 after an operation to remove gall stones caused a tear in the lining of her bowel.

Mrs Dodd, of Rolls Avenue, underwent two further operations in order to correct the problem, but never recovered.

At an inquest on Thursday, it emerged because Mrs Dodd's medical notes had not been filled in for a period of five days, it appeared she had not been examined for nearly a week.

The inquest, before Cheshire deputy assistant coroner Robert Wilson-Hunter, heard evidence from Mrs Dodd's daughter Julie Leach who spoke of the family's anger at her treatment.

'I'm livid, the whole family is. When they talk about care, we hardly saw anyone until she went to the high dependency unit.' She added it was only once her mother was moved to the intensive care unit the family felt they were properly informed.

The inquest also heard a scoring system to determine the seriousness of a patient's condition was miscalculated, and although it could not be said the human error contributed to Mrs Dodd's death, coroner Dr Wilson-Hunter said a correctly tallied score would have alerted doctors there was a problem sooner.

Mr Arif Khan, the surgeon who operated on Mrs Dodd, said: 'There are times when you get the optimum care and there are times when you expect more and it does not happen.'

He said the hospital trust needed more staff and better resources the same old excuse .

The inquest heard that Mrs Dodd had seen a member of the surgical team during the five days her notes were left blank, but Dr Wilson-Hunter criticised the communication breakdown.

He said: 'Nothing was written, and it's imperative there are good entries made.'

He returned a verdict that Mrs Dodd had died due to multiple organ failure.

Dr Wilson-Hunter added: 'She died as a result of a recognised complication in a necessary surgical procedure, but there appeared to be problems with doctors communicating with each other.'

Reads Complaint

I have a friend - who is 93 years old - in Leighton Hospital. When he was first in, we (a group of us who are friends - he has no proper relatives), objected because, with a broke femur, he was constantly being shuffled to the back of the emergency list - 'in case someone might have a car accident because of the icy weather'.

In the end we stated that we were aware that they were waiting until he developed pneumonia, when they would probably refuse to operate on him anyway - and then he would die. So then he got his operation, because a few of us were complaining - and showing that we would continue.

Following his operation, he could not eat the food.

Being a lifelong vegetarian, he found what was presented, to be inedible. We complained that he was turning his face to the wall. He existed on bananas for the first week - which were brought in by concerned friends. When I asked the staff nurse whether he was seen to be eating at all - because was aware that he was not eating - I also asked whether anyone had sat with him to ensure that he was eating. I was told that "he has the use of his hands".

Curiously, I do not feel that this is a good attitude - in a nurse.. especially to a man of 93 years old, who - refusing pain relief - has just had a major operation..

It took far too long - over a week - to get a dietician to see him.

I am aware that the nurse who was seeing off the elderly. at Leighton, has been jailed - eventually - for her actions. But, I am sure that others, who possibly knew what was going on, are still working at Leighton. On current experience, I am not reassured by the behaviour of nurses. I feel the need to watch them - and their practices. My friend seems to be going through his third gut infection, in that hospital, at the moment.

Is that really good enough?

Charlotte Peters Rock

Leighton Hospital

February 24th 2006

The Patient Advice and Liaison Service (PALS) is a free, confidential service for patients, their families and carers. It provides “on the spot” information, advice and support with the aim of resolving any problems or difficulties that you experience quickly and effectively.

Contact Details:
Patient Services Manager
Mid Cheshire Hospitals NHS Trust
Middlewich Road
Crewe
Cheshire
CW1 4QJ
Tel: 01270 612410
Leighton Hospital

Contact Details

Carolyn Kural
Patient Services Manager
Mid Cheshire Hospitals Trust
Tel. 01270 612378
E-mail: Carolyn.Kural@mcht.nhs.uk

If you would like independent support, the local Independent Complaints Advocacy Service will be able to help and guide you through the NHS complaints procedure. Their contact telephone number is 0845 120 3735 or you can write to them at the address shown below:-

Cheshire Independent Complaints
Advocacy Service
Brunner Guildhall
High Street
Winsford
Cheshire
CW7 2AU

Contact the Healthcare Commission:

FREEPOST NAT 18958
Complaints Investigation Team
Manchester, M1 9XZ
Tel: 0845 601 3012
Fax: 020 7448 9180
complaints@healthcarecommission.org.uk

Ledward Victims Group
c/o Mrs Janet St Pier
Honorary Secretary
85 Church Meadows
Sholden, Deal
Kent, CT14 9QZ

Email: janet.st.pier@ukgateway.net or janstpier@aol.com

The Ledward Victims Group is hoping to achieve the following:

To establish why an incompetent surgeon was allowed to carry out surgery for 16 years.

That a "vetting" procedure is put in place for all doctors/surgeons, and that there is a governing body set to review doctors/surgeons on a regular basis.

There should be "freedom" to all medical staff to speak of any concerns or observations they have about senior colleagues without fear of reprisal.

There should be an easier way for a patient to complain without being fobbed off.

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Medical Accidents

IFBQ
Unit 6
The Oaks Business Village
Revenge Road
Lordswood
Kent
ME5 8UD

Email: ylindridgeifbq@aol.com
Website: http://www.medical-accident.co.uk/frames.htm

Our aim is -

To support all patients and to work with you to reduce medical accidents through
information sharing and education

      Support is a 2-way process
      We want to help you, but we need you to help us with
      information, and pinpointing our priorities
      We believe that all patients have the right to:

           Be listened to
           Be respected
           Have a say in their own treatment
           Be kept informed of all options
           Be treated by healthy, competent medical personnel
           Be treated in hygienic conditions
           Be treated in well-managed organisations

     We are a patient-led group; we apply business-accepted processes, standards and solutions
     to medical concerns
     Our approach is caring and supportive. Our aim is to fund our services to patients at minimal
     / no cost to the patient
     We have been successful in business through our approach, and wish to help others have a
     better quality of life
     This initiative was launched by Yolande Lindridge; her intervention and approach to medical
     issues affecting her and her family led to:
     Her son having the best quality of life available to him
     Containing her own breast cancer over 7 years without the intervention of drugs
     Improving dramatically her osteo-arthritis over 11 years without the intervention of
     drugs / surgery
     Her mother having a better quality death than that which was on offer to her
     Saving her own life in hospital
     She must be doing something right!

WE WANT TO USE OUR EXPERIENCE AND APPROACH TO HELP YOU.

WE NEED YOU TO TELL US ABOUT YOUR EXPERIENCES, GOOD AND BAD.

Please feel free to E-mail us if you have any queries or if you would like further
information.

All information received will be dealt with confidentially.

Together reducing the risks for patients
Copyright (c) IFBQ, 2000
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Medical Ethics Alliance

Springhill House
Springhill Lane
Wolverhampton
WV4 4TJ
United Kingdom

Fax : +44 1902 340100
info@medethics-alliance.org
http://www.medethics-alliance.org/

Medical Ethics Alliance is a non-profit making organisation and has been established to promote pro-life policies

******************************************************
Medical Litigation

http://www.medneg.com/, is subscriber based and the annual fee is £120 plus vat (£141). Our case database, and all other data bases as described below are only available to subscribers.

Established in 1998, is now used by most clinical negligence practitioners, including the NHS Litigation Authority, who enjoy the following unique benefits:

· a Confidential Index of over 1,000 experts under specialities who have testified in open court with relevant judicial comment - updated monthly;

· fast law reports, based on official transcripts, with full analytical headnotes, tables of cases and indexes prepared by experienced members of the Bar.

· authorities considered, applied, distinguished, overruled and otherwise judicially considered;

· indexes of over 1,200 practising lawyers with direct links to reported cases in which they have appeared - and the results;

************************************************
MRSASUPPORT
46 Great Stone Road
Northfield
Birmingham, B31 2LS

Tel: 0121 476 6583

Email: info@mrsasupport.co.uk

Website: www.mrsasupport.co.uk

The number of cases of MRSA is likely to rise to more than 100,000 over the next 12 months. To date, around 7,000 patients have contracted MRSA each year in hospital and 5,000 die each year as a direct cause.

MRSASUPPORT:

Formed to provide practical and moral support to all involved.

Most patients don't know that they have been infected and then when informed don't know what to do!

Most hospitals call MRSA an "infection" without telling the whole truth.

As well as offering immediate help, in conjunction with HAIR (Hospital Acquired Infection Register) we shall campaign for a cleaner approach to hospital hygiene.
Members of MRSA SUPPORT have published a booklet aimed at helping hospital patients and visitors to defend themselves from picking up the MRSA bug. Compiled by their chairman Tony Field, the booklet entitled "MRSA - A PATIENT'S DEFENCE!" outlines practical steps which can be taken to help prevent the spread of the deadly infection.

The booklets cost £1.00 (including postage).
To join the group; the annual subscription is £7.50 (this includes the booklet and 10 newsletters).
Please make cheques payable to MRSA SUPPORT (Please remember to include your name and address. Thank you.)

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NHS Code of Practice on 'Openness in the NHS'

This NHS Executive website outlines the Codes of Practice and provides information on what information NHS Trusts are obliged to provide.

Website: http://www.doh.gov.uk/nhsexec/codemain.htm#codeprinciple

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Patients' Association
************************************************
Patient Information Leaflets

Website: http://www.mentor-update.com/

PILs has a huge self help database
(choose text only version if you have problems accessing the self help database)

************************************************
Patient UK

Website: http://www.patient.co.uk/

This is a UK website, aiming to help non-medical people find information about health issues primarily from UK sources. Health professionals may also find the information useful. Many useful organisations listed here.

************************************************
Public Concern at Work

Suite 306
16 Baldwins Gardens
LONDON EC1N 7RJ

Tel: 0171 404 6609
Fax: 0171 404 6576
Email: whistle@pcaw.demon.co.uk

Public Concern at Work promotes accountability and good practice in
the workplace. We do this by helping ensure concerns about serious
malpractice are properly raised and addressed before the public interest
is harmed. Recognised by the UK government and others as the leading
organisation in this field, we are a completely independent charity.

******************************************************
Relatives' Association

Tel: 0171 9166055

************************************************
Self Help UK

Website: www.self-help.org.uk

Self Help UK provides a searchable database of over 1,000 self help organisations and support groups across the UK that offer support, guidance and advice to patients, carers and their relatives

************************************************
SIN (Sufferers of Iatrogenic Neglect)
SUFFERERS of IATROGENIC NEGLECT
Iatrogenic = Medically Induced Damage

For information please contact either Co-Director:

Gillian Bean
Tel/Fax: 0115 9431320
e-mail: sinfo@cwcom.net
or
Margaret MacRae
Tel/Fax: 0192 4407195
e-mail: Mag@sinfo.freeserve.co.uk
website: http://www.sin-medicalmistakes.org/

SIN is a pressure and support group for victims of poor medical care and their relatives who wish to improve standards in the NHS.

************************************************
UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting)
23 Portland Place
London, W1N 4JT

Tel: 0171 6377181
Fax: 0171 4362924

************************************************

Voluntary Euthanasia Society

13 Prince of Wales Terrace
London W8 5PG

Phone: 0171 937 7770
Fax: 0171 376 2648
E-mail: info@ves.org.uk
Website: http://www.ves.org.uk/index.htm

The Voluntary Euthanasia Society campaigns for wider choice at the end of life. As well as our political campaign to legalise assisted dying, we also supply living will forms for the advance refusal of medical treatment.