Hospital errors blamed for death of grandmother
10 Kings Hill Avenue, Kings Hill, West Malling, Kent ME19 4AR A catalogue of errors and missed opportunities led to the death of a grandmother left severely dehydrated at Maidstone Hospital.
Edna Thompson was rushed to the Hermitage Lane site in September last year with a suspected malignant glaucoma in her right eye.
She was prescribed mannitol, a powerful diuretic and died from an acute kidney injury just under a week later, despite family repeatedly warning she was becoming dehydrated.
A two-day inquest heard if doctors and nurses had stopped the medicine earlier, the 85-year-old would still be alive.
The coroner was told not all medics caring for the Harrietsham mum-of-three were aware of the risks posed by mannitol.
It was initially prescribed by glaucoma fellow Dr Albrna Dardzhikova on an ongoing basis to reduce pressure in Mrs Thompson’s eye. This was causing her intense pain and another medicine, diamox, failed to work.
After a review a day later in which Mrs Thompson was referred to Moorfields Eye Hospital, Dr Dardzhikova decided to continue the mannitol. She said she made this decision in conjunction with Mr Ejaz Ansari, a consultant ophthalmic physician.
But the coroner said there was no evidence from Mr Ansari as to whether he agreed with the continued mannitol use.
The coroner also heard it was ‘highly unusual’ for the drug to be given on more than two occasions or within 48 hours. Mrs Thompson received it for five days before her sudden deterioration.
Dr Dardzhikova told the family: “I just want to apologise and express my condolences to the family and to say I am really sorry for your loss.”
Dr Maria Dimitri, an ophthalmologist, saw the patient in an emergency eye clinic after she was admitted.
She told the court she did not implement daily reviews as she was unaware the former librarian was still taking the drug because her department kept separate records.
The coroner ruled this hampered nurses providing care and led to fluid balance not being monitored until far too late.
Giving a narrative verdict on Wednesday, senior coroner Patricia Harding said it was clear the mannitol was not reviewed and its diuretic effect not recognised until too late.
She said: “I am further satisfied on the balance of probabilities Mrs Thompson would not have died when she did but for the continued use of mannitol which caused her to become dehydrated.”
She said she would not issue any recommendations.
Maidstone and Tunbridge Wells NHS Trust apologised and said it has made improvements.