Woman dies after tests mix up

Communication breakdown: Gladys Wood, 83, died due to infection.
Communication breakdown: Gladys Wood, 83, died due to infection.
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A BREAKDOWN in communication led to a Doncaster pensioner being discharged from hospital with a fatal infection.

Test results on 83-year-old Gladys Wood were received by Doncaster Royal Infirmary doctors the day after she went back to a care home in Sprotbrough, but they were not passed on.

A Doncaster inquest heard a separate mix-up at Richmond nursing home in Allendale Drive then meant staff delayed giving her the antibiotics prescribed by an emergency doctor for the infection.

Mrs Wood, a widow, died a week later.

The hospital has apologised for its actions and has since changed procedures to ensure test results are reported after patients have been discharged.

Detectives investigated Mrs Wood’s death but found there was no criminal case to answer. Her family said they were satisfied with the outcome of the inquest.

Mrs Wood, a mother of three sons, was taken to Doncaster Royal Infirmary in April 2011 after falling at the home and breaking her thigh.

After undergoing successful surgery, a nurse took a urine sample because of concerns about a possible infection but Mrs Wood was discharged to the Richmond on April 18, the day before the results were sent from the lab.

They showed the patient had a bacterial infection in her urinary tract, which was the cause of her death in the home on April 26.

In the meantime Richmond staff had become concerned about her deterioration and an out-of-hours doctor prescribed antibiotics and a saline drip to rehydrate Mrs Wood after an emergency care practitioner saw the patient.

Richmond nurse Gaynor Millson told the inquest she was given the impression that putting the saline drip in was the priority, and expected another nurse would start administering the liquid antibiotics later.

But when Mrs Wood’s son, Brian Leivers, visited the next day he discovered the antibiotics had not been given and the prescription was still on the file. The night nurse denied being told about the antibiotics by Mrs Millson.

Mr Leivers told the inquest: “I didn’t think she should have come out of hospital anyway, but I wasn’t aware of the infection.”

When the antibiotics were prescribed he offered to get them from a chemist but Mrs Millson told him, ‘We’ve got it covered’.

“I went the next day and hoped to see a real improvement but she was the worst I’d ever seen,” he said. “She looked really poorly and I was taken aback by her appearance.

“I asked a nurse about the antibiotics and she kind of shrugged her shoulders. She said she was not on any antibiotics. That was when the prescription was found and I realised she’d not been on them. They told me she’d only got about a week to live.”

Det Insp Rich Partridge told the inquest: “There was no evidence to suggest the death of Mrs Wood was a crime. The medication that was omitted would not have prevented the death of Mrs Wood and there was nothing to suggest any criminal activities in the care home.”

Recording a narrative verdict, Assistant Coroner Mark Beresford said because of conflicting evidence about the non-administration of the antibiotics he was unable to determine which version was correct, although it had no real bearing on the events that led to her death.

But Mr Beresford said he had a number of concerns about the case.

The first was the decision to discharge Mrs Wood when the results of the urine test were still pending. The second was that, when they were known at DRI, no action was taken to tell the care home or her GP.

Mr Beresford said it was both a ‘systemic issue’ and the failure of the individual house officer at DRI.

The coroner said there may also have been a failure of communications between the emergency care practitioner and care home staff, as well as individual nursing staff at Richmond.

Mr Beresford said he had been reassured about changes in procedures at DRI which have been put into effect regarding the reporting of results on tests on patients who have been discharged.

After the inquest, a spokesman for Doncaster and Bassetlaw Hospitals NHS Foundation Trust said: “We are truly sorry this occurred and offer our deepest sympathies to Mrs Wood’s family.

“We have taken action to minimise as far as possible the risk of anything like this occurring again. Staff who request tests have a duty to follow them up and check the results, and staff who receive test results have a duty to report them to the medical staff.

“We are also rolling out the electronic reporting of test results, which will automatically flag up any results that haven’t yet been viewed.”