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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

An elderly patient forced to lie next to a dead body for five hours in Leighton Hospital claims he would 'rather die' than go back there. Fred Green has slammed the Crewe hospital over the 'distressing treatment' he suffered during his five-day stay. The hospital came under fire last month from the Healthcare Commission about the way it treated elderly patients. It found serious lapses in the care of the elderly found lying in their own mess, nurses ignoring calls for help and of drug rounds not carried out on time with tablets left out of reach of patients. Watchdogs were appalled at the lack of attention by staff which they said 'adversely affected the dignity, morale and health' of old people in their care. Measures are in place to improve standards of care - but Mr Green, of Northwich, says a lot more needs to be done. The 75-year-old told the Chronicle the worst part was when a patient in the bed next to him died and was left there for five hours.

Leighton Hospital denies storing organs

From the Guardian Series, first published Monday 12th Feb 2001.

BOSSES at Leighton Hospital have denied claims that it stores the organs of dead patients.

The Mid Cheshire Hospitals Trust, which runs Leighton, said this week that it does not retain organs once a post mortem has been carried out to establish the cause of death of deceased patients.

But it has now set up a helpline for concerned relatives.

The announcement follows the publication of Michael Redfern's inquiry into Liverpool's Alder Hey hospital, where more than 800 organs were removed from children without the consent of parents.

But the Trust has also set up a helpline for anyone who is still concerned about the possibility that organs might have been retained following a post mortem.

In a statement to the Guardian, Leighton's chief executive Simon Yates, said: "I fully appreciate the concern that bereaved relatives will be feeling on the recent reports.

"I can confirm that post mortems are carried out on the Leighton Hospital site, when these are required by the coroner or when relatives agree to a hospital post mortem.

"However, whilst organs may sometimes be removed temporarily as part of this procedure, the Trust does not retain organs once the cause of death has been established.

"Any organs removed during the post mortem will have been restored to the deceased."

But Rosemary Oakes, a former coroner's office worker from Stanthorne, believes the number of post mortems carried out at the hospital is far too high, and often unnecessary.

"People should be made aware of the fact that post mortems are often carried out often without any reasonable explanation," she said.

The helpline number for more information about the Trust's procedures and policy on organ retention is 01270 501646.

Hospital criticised over death
Leighton Hospital, in Crewe The hospital trust spokesman said lessons had been learnt A hospital in Crewe has been criticised over mistakes made during an operation which led to the death of a patient.

The Health Service Ombudsman, Ann Abraham, upheld a complaint against Leighton Hospital by the family of a man who has not been named. The man suffered from Parkinson's disease and could not speak. He was admitted to the hospital because of problems he had eating but the next day he died.

Internal bleeding

Doctors had put a feeding tube into his bowel, using a local anaesthetic, but the surgeon put it in the wrong place, and the man developed internal bleeding and peritonitis. The Health Service Ombudsman criticised the Mid Cheshire NHS Trust which runs the hospital. The ombudsman found doctors had broken General Medical Council guidelines on communicating with the patient and said the risks were not explained properly. She also said the wrong type of anaesthetic was used and the operation was performed in such a way that death was inevitable.
Lessons learnt

The Chief Executive of the Mid Cheshire Hospital Trust Simon Yates said lessons had been learnt.

"What we have to do is make sure that whenever mistakes are made we can learn from them," he said.

"We should not drive mistakes underground by always go out looking for somebody's head.

"We are continually trying to set up systems where clinical staff are open if things go wrong."

A hospital in Crewe has been criticised over mistakes made during an operation which led to the death of a patient.

Parliamentary health ombudsman find Leighton Guilty

Premature discharge, unacceptable delay in administering antibiotics, incorrect administration of Heparin Leighton found to be guitly

Case no. E.1529/01-02 - Avoidable death as a result of inadequate care and treatment

Mr M was admitted to Leighton Hospital, Crewe, because of recurrent iron deficiency anaemia and feeding difficulties. He suffered from advanced Parkinson’s disease and was unable to speak. One week after being admitted, a consultant physician made an unsuccessful attempt to insert a feeding tube endoscopically and referred Mr M on to a surgical registrar to have the tube inserted surgically into his small bowel. The registrar considered that, due to Mr M’s general ill health and the fact he had a rigid curvature of the spine, the procedure should be performed under local rather than general anaesthesia. The disadvantage of local anaesthesia was that it did not offer any relaxation of abdominal musculature and the rigid muscles could not be retracted for an optimum view. The registrar attempted to perform the procedure. However, he found difficulty in distinguishing between the large and small bowel, which he considered lacked the normal characteristics, and erroneously placed the feeding tube into the large bowel.

HOSPITAL UNDER FIRE

 

From the Guardian Series, first published Thursday 25th Mar 1999.

LEIGHTON Hospital has been blasted by a damning independent review following the death of an Alsager man who absconded from a psyciatric ward.

Settlement is agreed after birth left child with severely disabled arm

A SANDBACH family have received compensation from Leighton Hospital for 'medical errors' that left their child disabled.

OAPs are 'scared stiff' of going into hospital

From the archive, first published Thursday 16th Feb 2006.

A CREWE and Nantwich pensioners' group has said that elderly people are 'scared stiff' of going into Leighton Hospital following attacks on the centre's quality of care.

Claims give health trust a headache

From the archive, first published Thursday 9th Feb 2006.

CASH-strapped Leighton Hospital and Victoria Infirmary is facing another financial headache as it contends with a series of claims for medical negligence.

The Guardian has already revealed how Mid Cheshire Hospitals NHS Trust is facing a £5.7 million deficit this year and plans to cut the number of beds, introduce a recruitment freeze and axe managers.

Now a new report, which went before the board on Monday, reveals the trust could pay out more than £300,000 in medical negligence claims from South and Mid Cheshire patients.

The most serious case involves a patient who alleges there was a three-year delay in him being diagnosed with non-Hodgkin's lymphoma.He is claiming damages of £150,000 and the costs for both sides could run to another £30,000, hospital bosses have been told.

One of the major claims - for £25,000 damages - is by a patient who says the hospital failed to diagnose a heart aneurysm.

Lawyers representing the family of another Leighton patient are claiming £20,000 damages, alleging the hospital failed to monitor a patient for vascular disease.They claim the patient developed septicaemia and died.

Other claims include an allegation that staff in the obstetrics department failed to notice 'signs of foetal distress' with a woman patient which led to a baby being stillborn

Further claims by medical staff, involved in a variety of industrial accidents, from being struck by a falling drip stand to a back injury sustained while handling a 10-litre milk carton, totalling at least £17,000, have also been lodged with the trust.

Pensioner died in hospital

From the archive, first published Wednesday 8th Feb 2006.

AN operation to cure lung congestion may have contributed to the death of a retired Hartford accountant, an inquest has heard.

Former ICI employee Peter Gordon Crutchley, of Eaglesfield, died at Leighton Hospital on April 28, 2004 after being admitted with a urinary tract infection 10 days earlier.

But the inquest at Crewe Magistrates' Court on Friday heard the post mortem examination carried out on the 74-year-old determined the cause of death as adult respiratory distress syndrome, which may have been related to an earlier operation to combat a build-up of fluid in the pleura.

Doctor in childbirth case is not struck off

From the archive, first published Thursday 12th Jan 2006.

A LEIGHTON Hospital doctor will not be stripped of her right to practise following claims she botched the care of a baby in childbirth.

Dr Lynda Coughlin, of Wood Sorrel Way, Lowton, near Warrington, appeared before the General Medical Council (GMC) fitness to practise panel after a mother's child was delivered stillborn in January 2004.

The doctor admitted 'inadequate and inappropriate' medical care for the woman, but denied serious professional misconduct.

Medical watchdogs agreed that the incident was the result of a single mistake for which Dr Coughlin demonstrated 'immediate insight and remorse'.

The GMC panel judged that her failings amounted to misconduct but said that her fitness to practise was not impaired.

But Dr Coughlin, a specialist registrar in obstetrics at Leighton, may still receive a warning.

WOMAN DIED AFTER TAKING DRUG FOR DIABETES

 

From the archive, first published Wednesday 26th Oct 2005.

A MIDDLEWICH woman died after suffering a rare reaction to a common drug given to people with diabetes.

Daughter Janice Hassall said: "I believe that she was left to die."

Mum stranded by baby ward closure

From the archive, first published Friday 5th Aug 2005.

A WOMAN in advanced labour had to endure a 17-mile journey to Macclesfield after Leighton Hospital in Crewe turned her away because its maternity unit was shut.

Superbug cases rise in hospitals

 

From the Guardian Series, first published Wednesday 29th Jun 2005.

CASES of superbug MRSA have risen at mid Cheshire hospitals - despite a nationwide decline of more than six per cent.

The latest Department of Health figures show the national infection rate is currently at its lowest recorded level, yet the Mid Cheshire Hospitals NHS Trust - responsible for the Victoria Infirmary, Northwich, and Crewe's Leighton Hospital - has seen a rise from 31 cases per 1,000 bed-days in 2003-04 to 37 incidents for 2004-05.

Two years of misery

From the Guardian Series, first published Thursday 12th May 2005.

A CREWE mother is taking legal action against Leighton Hospital, claiming a botched operation has left her in misery for almost two years.

Vicky Oakes, 31, of Richmond Road, underwent a Caesarean section in July 2003 giving birth to her fifth child Alannah.

But it was not until the day after that she noticed severe bruising and a lump in her stomach.

She said: "They told me it would go away when things settled down and they discharged me after four days.

"But the day after I was rushed back in with a severe internal infection. Someone looked at me and I was just given a course of antibiotics."

When she was still in pain two months later she went to see her GP.

She said: "Following a CT scan, he said it was definitely a hernia caused during the section when they had cut through into my bowel by mistake."

She was eventually put on a waiting list, but told the earliest appointment was November 2004. And when she finally went for the pre-op she was told it had been cancelled.

A further appointment in January was also cancelled, as was a third in February.

Vicky went in again on Friday and waited two hours for a bed before being told she would be next into theatre.

She said: "Five minutes later I was told to get dressed as my op had been cancelled and the surgeon had gone to see private patients."

The married mum-of-five said her quality of life has been decimated since the C-section.

She said: "I can no longer walk my children to school and I struggle with everyday things like picking my daughter up and shopping.

"I have never even had an apology from the hospital. If I'd caused the problem I could perhaps understand it, but they have caused it.

"I did tell them something was wrong after the birth, only to be told it was all in my head."

The Trust's director of service development Mandy Donald said: "Naturally, we are concerned if any patients are dissatisfied with the health care we provide and should like to extend our sincere apologies in this case.

"We do everything in our power to avoid postponing operations and we deeply regret and fully understand the distress and inconvenience which this causes to patients.

"However, it must be emphasised that seriously ill patients must always take priority over other, less urgent cases.

"Unfortunately, sometimes the unpredictable nature of theatre lists and availability of beds means occasionally it's not always possible for surgery to go ahead as scheduled."

Hospital fails to hit treatment targets

From the Guardian Series, first published Thursday 7th Apr 2005.

A NEW out-of-hours block has this week been opened at Leighton Hospital as part of measures to improve the handling of emergency patients.

Health bosses in charge of the Crewe hospital were summoned to London by the Department of Health after the A&E department failed to meet government targets for treating patients.

Hospital defends new 'superbug' infection rates

From the Guardian Series, first published Wednesday 16th Mar 2005.

NEW figures released show that infection rates of the MRSA 'superbug' have risen at Leighton Hospital - despite a nationwide fall to a four-year low.

Government statistics have revealed that the number of patients at the Mid Cheshire Hospital Trusts' hospital suffering from MRSA has made it into the top 10 worst in the country.

The number of reported incidents has risen from 14 in the six months from April to September 2003, to 20 cases in the same period last year.

Mandy Donald, director of service development at Leighton Hospital, defended the hospital's performance. She said: "We are continuing to work hard in all areas related to MRSA. There are numerous examples throughout the hospital of continued action.

Operation cancelled after superbug fears

From the Guardian Series, first published Thursday 22nd Jul 2004.

A TERRIFIED Lach Denis woman is so scared of contracting the MRSA superbug she has refused to keep her pre-operation appointment at Leighton Hospital.

And now she has been taken off the consultant's waiting list.

Marilyn Hulse had already been waiting 15 months in excruciating pain for an orthopaedic operation to be carried out on her shoulder.

I WARNED THEM THAT NURSE WAS

From the Guardian Series, first published Wednesday 7th Jul 2004.

A DANGER

A WINSFORD woman warned Leighton Hospital that Barbara Salisbury was dangerous more than three years before she attempted to murder two patients.

Kathleen Suckley, of Dee Square, Winsford, wrote an eight-page letter to Leighton Hospital in December 1998, outlining the way her husband, Roy, 74, was treated on ward five.

Speaking to the Guardian this week, Mrs Suckley said: "Maybe if my letter had been taken more seriously then she wouldn't have had the opportunity to commit the crimes that she did.

Hospital assessment raises concerns

From the Guardian Series, first published Wednesday 31st Oct 2001.

A LACK of staff and old anaesthetic equipment are among the concerns raised after an assessment of Leighton Hospital.

Mid Cheshire Hospitals Trust has now published a three-year action plan to combat the problems raised in the Commission of Health Improvement (CHI) report.

The 70-page report is the result of months of investigations by CHI, which included interviews with dozens of patients and staff and a week-long hospital visit.

Simon Yates, the chief executive at Leighton, said he had expected the various concerns to be raised and put the problems down to a lack of staff and money.

'Low morale' in hospital's casualty revealed

From the Guardian Series, first published Wednesday 21st Feb 2001.

A FORMER employee at Leighton Hospital has revealed that staff are demoralised and morale is very low in the Accident and Emergency department.

The ex-employee, who does not wish to be identified, says junior doctors work in the department with little experience.

"It's like being in a nightmare, it's absolutely soul destroying. What people don't realise is how little cover we have," the ex-employee said.

"The main thing is the frustration among staff.

"Everybody, nursing staff, junior doctors and permanent staff feel so demoralised and fed up with the whole situation."

The revelations were prompted by our story two weeks ago when we told how a 12-year-old boy had to wait almost six hours because there was only ONE doctor covering the busy department.

Hospital's in patient psychiatric care is in need of a review

From the Guardian Series, first published Wednesday 21st May 2003.

I WAS dismayed and saddened to read the coroner's comments following the suicide of a patient at Leighton Hospital. Regrettably though, the comments are long overdue.

The Psychiatric Unit has a lot to answer for. I was a patient at the time of the suicide in question and witnessed several incidents of the type mentioned by the coroner.

The reputation of the service among patients is abominable. Furthermore as an inpatient, complaints go unheeded.

At a time when the government is obsessed with achievement of quality healthcare we must ask why the standard of in-patient psychiatric care in Crewe is poor.

When will patients in Crewe receive in-patient care with the dignity and compassion we deserve?

Hospital nightmare for mums in labour

Aug 3 2005
By Ben Jervis, Crewe Chronicle 

TWO mums-to-be from South Cheshire were left facing a desperate search for beds after Leighton Hospital's maternity ward closed.

Claire Pheasey from Tennyson Close, Rode Heath, and Faye Talbot, of Lime Tree Avenue, Crewe, were turned away after they were told the ward had been shut because of staff sickness.

A nightmare 48 hours began for the women when Claire, who had planned to give birth at the Crewe hospital, rang to say she had gone to labour.

When she called back later in the day she was told the maternity unit had been closed and was given the number for another hospital.

Mum died after 'routine' surgery

 

From the Guardian Series, first published Thursday 14th Oct 1999.

Report by

MHARI KELLY

A DOCTOR made two critical mistakes which led to the death of a 62-year-old woman, an inquest has heard.

Margaret Poole died after routine surgery at Leighton Hospital went wrong.

An inquest in Crewe heard that Mrs Poole would almost certainly have been alive today - if the errors had not been made in surgery.

Dr Kaleem Toori was supposed to drain fluid from her right lung - but started the procedure on her left lung by mistake.

He should then have ordered for an urgent X-ray to be taken to check there had been no damage - but he failed to do so.

Cheshire coroner Nicholas Rheinberg recorded a verdict of misadventure on Mrs Poole, of Shipbrook Road, Rudheath.

But after the inquest, Mrs Poole's daughter, Judith Finney, of Gowy Walk, Winsford, said that she was not satisfied with the verdict and would fight to have Dr Toori struck off the register.

She said: "We are going to pursue this with the General Medical Council because he should be down graded or struck off completely. At the end of the day he admitted his mistakes so something should be done.

HOSPITAL BLUNDER COSTS £1.7m

 

From the Guardian Series, first published Thursday 8th Oct 1998.

A TEENAGE twin, brain damaged after being starved of oxygen during her birth at Leighton Hospital, has won £1.7million damages in London's High Court.

South Cheshire Health Authority will pick up the tab after a lengthy legal battle.

Amanda Ludow is 13, but the authority only admitted negligence in February this year.

The court heard how the youngster, now living in Gosport, Hampshire, was seriously disabled after suffering hypoxia, leaving her in need of constant care for life.

Amanda and her twin sister Katie were born in September, 1985. Katie was the younger by eight minutes and came through the birth unscathed.

Amanda is cared for by her mother and step-father, Joanna and Stephen Fields and stays with her father, David Ludlow, at weekends.

Judge Mr Justice Bell paid glowing tribute to the devoted care lavished on Amanda by all three.

The court heard that the youngster suffered from Dyskenetic cerebral palsy. Although not as badly off as some cerebral palsy vicitms she had grave problems with mobility, some hearing loss and severe learning difficulties.

"She has no sense of danger and has to be supervised 24-hours-a-day. Her mother and step-father are in the process of buying a new home better suited to her needs," said the family's counsel Mr Adrian Whitfield QC.

Mr Stephen Miller, for the Health Authority, said that the authority accepted there had been lack of care for which they expressed their sincere apologies.

After the hearing, Amanda's father said the settlement meant that the youngster could now receive the high level of care she would need for the rest of her life.

"We are relieved that this lengthy legal process is over. However, we are concerned that some of the medical procedures appear to have been inadequate and we will be seeking assurances that these procedures have been improved, both locally and nationally," he said.

The birth trauma occured well before the formation in 1991 of the Trust that is now responsible for Leighton.

Chief Executive, Simon Yates, said that he was unable to comment on the cause or subsequent action taken over medical procedures as he had no knowledge of the case.

Liability rested with the Health Authority which managed the hospital at the time.

"But the Trust is very pleased for Amanda that this matter has reached a conclusion. We hope the payment will help her achieve the best quality of life possible," he added.

THE length of time it has taken the Health Authority to admit negligence is to be queried by watchdog organisation the Crewe Community Health Council.

Chairman Mr Ron Stokes said "It seems to have taken a tremendously long time to sort out and I intend to ask questions about it."

Hospital under fire over care for suicide victim

 

From the Guardian Series, first published Thursday 29th Jan 2004.

A NANTWICH man - released from Leighton Hospital's psychiatric ward three days after being admitted for trying to kill himself - took an overdose and died.

An inquest into the death of Martin Paul Upham, aged 37, of Murrayfield Drive, Willaston, heard how an administration mix-up meant he did not receive a visit from a community health nurse to check on his wellbeing.

On January 8, 2003, depressed Mr Upham plunged a broken glass into his left wrist in a suicide attempt, four days after suggesting he was going to kill himself with medicine, the Crewe hearing was told.

He was transferred to the Countess of Chester Hospital before being admitted to Leighton's psychiatric ward.

Mr Upham was given sedatives before he was released after becoming agitated when his wife Diane visited and told him their marriage was over.

He was discharged despite protests from his concerned family and took a lethal cocktail of medication and alcohol, a week later, on January 23.

Mrs Upham said: "There was a plan that he would be supported by the community health team. We got a letter the day after he died to arrange an appointment but that was the first point of contact.

"The day before he died I had a conversation with the community health team to see why nothing had happened."

Adrian Sherrat, a staff nurse on the hospital's Ward 21, said: "It appears the documentation went missing and when the community heath team received it, it had not been filled in correctly.

I had unfortunately forgotten to complete part of it."

Later Mr Upham's mother Jennifer said: "I'm not happy that notes went missing.

"I feel that my son was let down by the system.

"I spoke to someone at the hospital and said I wanted it recorded that I wasn't happy that he was being released.

"His whole mannerisms told you he wasn't right."

Dr Sarah Linney, who discharged him, said: "I only met him on his discharge on the Saturday. I wasn't aware he had expressed he wanted to die after the incident with the glass.

"We can force someone to stay against their will for 72 hours. But I didn't feel it was necessary.

"He was adamant that he wouldn't harm himself because of his children."

Recording a suicide verdict, Cheshire Coroner Nicholas Rheinberg said: "Martin Upham took his own life when the balance of his mind was disturbed."

Dr failed to spot killer bug

 

From the Guardian Series, first published Thursday 24th Jan 2002.

Dr failed to spot killer bug

A DOCTOR has admitted failing to examine a patient properly just hours before she died of a rare and deadly disease.

Dr Richard Pearson was on duty at Leighton Hospital's A&E department when Alison Farmer came in complaining of an allergic reaction to an insect bite.

However, the doctor failed to spot an infection that was in fact the deadly disease, Nacrotising Faciitis - known as the flesh-eating bug.

Mrs Farmer, aged 42 and of Fuller Drive in Wistaston, was sent home but collapsed very soon after and died after being rushed back to the hospital.

Dr Pearson, who has in the past been caught sniffing an anaesthetic drug while on duty at another hospital, appeared at an inquest into the death but denied being under the influence of any drugs or alcohol on the day in question.

At the inquest, Cheshire coroner Nicholas Rheinberg, launched an in-depth probe into what happened that day, September 11, 2000.

Mrs Farmer's husband, Robert, 45, told the court that his wife had a history of allergic reactions to Horse Flies and on the day before her death (Saturday) had said she had been bitten.

"I woke about 7.30am (on Sunday) took one look at her and thought you're not right, we phoned the GP service and they advised us to take her to the hospital," Mr Farmer said.

The court heard Dr Pearson saw Mrs Farmer at around 9am but heard conflicting accounts as to the extent of the doctor's examination of the patient.

Mr Farmer said he told the doctor that his wife had been shaking and that the insect bite was thought to be underneath the arm but maintained he never examined that area.

"He did not visually examine the area at that stage and I do not think he did at any stage thereafter. He examined her with his hands above the clothing.

"At some stage towards the end of our visit she said the tissue seemed to be hardening and was moving onto her breast and it was very hard and sore, but again I did not see Dr Pearson make a visual examination," he added.

Dr Pearson told the court he did not remember being told she had been shaking and he had seen a mark on the left arm, which he had taken to be the bite.

"I do not know why her clothes were not removed and I do not ever remember being told that there was an insect bite under the arm," he said.

When Mr Rheinberg questioned the fullness of Dr Pearson's examination he said: "I do not recall being told that the pain was further down the chest. I accept she was not fully examined."

Mr Farmer tried to question Dr Pearson, saying: "We are aware you have a history of substance misuse," but Mr Rheinberg said the questioning wasn't relevant although he asked if Dr Pearson had been under the influence at the time, to which he responded: "I was certainly not under the influence of drugs or alcohol on that day."

The court heard that a high pulse rate of 110 was recorded and a heartbeat of 136 and that Mrs Farmer was clammy and sweaty and various experts testified this should have been an indication of infection.

Dr Duncan Chambers, a consultant with A&E at Leighton Hospital, said: "It (Nacrotising Faciitis) is a very difficult diagnosis but I think it would have been reasonable given an appropriate examination to think of infection."

Recording a verdict of accidental death Mr Rheinberg said: "There is some degree of uncertainty or inconsistency in evidence as to what exactly happened between Mr Farmer and Dr Pearson.

"Alison Farmer may have been expected to have been referred onto a more specialist treatment regime, the best place probably being intensive care and the lack of treatment can be best categorised as a lost opportunity rather than the actual cause of Mrs Farmer's death."

Mr Rheinberg was assured changes had been made at Leighton's A&E department.

Chief Executive at Leighton Hospital, Simon Yates, confirmed Dr Pearson is still working at Leighton and that the hospital had already taken disciplinary action against him.

"The Trust accepts Mrs Farmer should have stayed in hospital," said Mr Yates.

Grieving mum speaks out over baby's death

 

From the Guardian Series, first published Thursday 26th Feb 2004.

A WINSFORD woman whose baby son died in Leighton Hospital days after he was born blames members of staff for causing the circumstances that led to his death.

Julie Jennings, 37, of Norman Drive, conceived baby Connor through IVF treatment after struggling for 15 years to have a child with her husband Simon, 38.

Connor was born at Leighton on August 3, 2002, but was immediately placed on a ventilator. Doctors established that Connor was severely brain-damaged and the decision was made by his parents to switch off their baby's ventilator on August 8.

Julie is still coming to term with her grief, but last week she made the brave decision to speak out about her family's ordeal.

She claims that her son died because of mistakes made by some members of staff who helped to deliver her baby, and has spent the past year-and-a-half piecing together information about his death she says was never volunteered.

She said: "Connor was taken from me immediately after he was born. I was banging on the walls asking what was wrong.

"The midwife came back in and said that my baby was born 'flaccid', then she just went back out. My family came in and we told them that Connor had died.

"Then the paediatrician said that they had resuscitated Connor but he was very poorly and they did not know what the cause was. They told us to be prepared to switch the ventilator off as he was severely brain damaged."

A letter from the NHS Litigation Authority (NHSLA) to the Jennings' solicitor, David Tweedie, on June 23 last year, admits that there was 'a breach of duty and limited causation' on the part of the hospital in Connor's death.

Yesterday, Tuesday, Steve Walker, spokesman for the NHSLA, said: "What the trust has accepted responsibility for is Connor's death."

Julie believes that the two major mistakes were a misreading of the cardiotocograph (CTG) monitor that checks a baby's foetal well-being during labour and a failure to carry out foetal blood sampling.

A spokesman for Mid-Cheshire Hospitals' NHS Trust would only say: "We are unable to comment on individual cases, but can confirm that this case is being dealt with through the trust's complaints process."

 

 

 

 

 

 

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