Catalogue of blunders at BRI led to woman's death

AN "amazing" mum 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 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 whether to take 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 the prescription was correct but forgot and failed to administer the drug. 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 whether it was appropriate.

"I got distracted looking after another patient and we were short staffed as well," she told the inquest.

She accepted that not giving the drug was a "failure" on her part.

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

"There was an awareness that it (Clexane) needed to be given but because it has not been signed for I know it was not," she said.

Junior doctor Susan Tetlow said Mrs Churcher had been making a decent recovery from a serious stroke. She said a health care assistant made her aware that Mr Churcher had reported concerns about his wife's leg. Dr Tetlow immediately checked her leg and ordered an ultrasound scan, fearing she had developed DVT.

She also noticed that Clexane seemed not to have been administered so rewrote the notes to make it abundantly clear what was needed.

Stroke physician Dr Peter Murphy, who had prescribed the Clexane, said Mrs Churcher had suffered a very serious stroke but had been making good progress. He had decided to administer the drug because she was at high risk of DVT.

"When I went to see the family they told me they were sure we did everything we could have for her," he said. "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.

"These include improving written and verbal communications between groups of staff and introducing teaching sessions, routine checks on patients for symptoms of DVT and improvements to the prescription chart."

Afterwards Mrs Churcher's husband Ray, and daughters Louise Morgan and Debra Callicott, said: "She was an amazing person. She was a brilliant mum, wife and a nan to two grandchildren.

"We miss her terribly and feel this was a good result."

Madeleine Pinschof, of Thompsons solicitors, said the family was considering a civil claim against the hospital.

She said Mrs Churcher had died "as a result of levels of care that fell well below what she and they had the right to expect".

She added: "Margaret's family are determined that no other elderly, sick and vulnerable patient should be neglected as Margaret was and that the hospital learns from the mistakes made in her care."