THE death of a great-grandmother who suffered serious kidney failure in hospital while being treated for a broken hip was ‘aggravated by neglect’, an inquest found.
Charlotte Tocher, aged 90, of Bartin Close, Ecclesall, Sheffield, was admitted to the Northern General Hospital after fracturing her right hip, and recovered well from surgery.
But Sheffield Coroner’s Court heard Mrs Tocher’s condition deteriorated rapidly as medical staff didn’t pay appropriate attention to her fluid balance.
Forms which monitored the amount of fluid the diabetic pensioner drank, as well as how much water she passed, were not properly filled in.
She developed a condition called oliguria – a low output of urine – which brought on acute kidney injury which led to her death last May.
After a review of Mrs Tocher’s case, a number of changes have been made to practice and procedure at Sheffield hospitals, including the routine involvement of a consultant geriatrician in the postoperative care of all older patients with hip fractures.
The inquest heard Mrs Tocher was previously ‘fit and active’, lived in her own flat at retirement complex Fitzwilliam Court, and drove a car until around six weeks before her sudden death.
Her daughter Judith said: “She was fiercely independent. Her death in hospital felt untimely.”
Mrs Tocher was initially admitted to the Northern General with stomach pains and swollen abdomen but after tests was declared ‘medically fit’ and discharged.
On May 12 paramedics were called to Bartin Close and found Mrs Tocher had tripped over and broken her hip.
Dr Fiona Creagh, a diabetes consultant at the Northern General, told the inquest fluid balance sheets were not fully completed on a number of occasions while Mrs Tocher was on the ward.
She added: “Acute kidney failure is often asymptomatic until a late stage, so clinically there are not clues, and observation-wise there were not clues – with the exception of the urine output, which was not measured.”
While in hospital, Mrs Tocher also suffered metabolic acidosis, where acid levels in the blood are higher than normal. The acidosis was caused by a drug called Metformin, which accumulated in her body due to the kidney problems.
David Throssell, deputy medical director at Sheffield Teaching Hospitals NHS Foundation Trust, said: “We have carried out a full review of the care provided to Mrs Tocher.
“Since her tragic death there have been a number of changes made to practice and procedure, most importantly the routine involvement of a consultant geriatrician in the postoperative care of all older patients with hip fractures.”
Assistant deputy coroner Professor Robert Forrest recorded a verdict that Mrs Tocher’s death was as a result of natural causes, aggravated by neglect.