Apology from hospital over drugs delay before death

KIDNEY PATIENT WOULD HAVE SURVIVED INFECTION, CORONER CONCLUDES

A WOMAN’S life may have been saved if antibiotics had have been given sooner, an inquest has heard.

Sylvia Lindsay had been due to celebrate her golden wedding anniversary just 10 days after she died at the Royal Derby Hospital.

Mrs Lindsay, 70, of Burton, was a kidney patient and died when she suffered an infection following an exploratory operation.

A few days following the surgery Mrs Lindsay’s health deteriorated, she was “struggling to breathe” and lay in a “foetal” position, her husband told the inquest. He also claimed nursing staff did not seem to know how to properly care for her.

Assistant coroner Rachel Syed concluded that based on medical evidence, antibiotics were not given quickly enough to Mrs Lindsay, which could have saved her life.

Concluding the inquest, Ms Syed said: “The trust concedes that there was a delay in giving prompt treatment.

“It then seems largely accepted by all that her condition continues to deteriorate and she is sadly pronounced dead in the early hours of September 16, 2014.”

An official medical cause of death was given as pulmonary embolism, a blockage of an artery in the lungs, which was caused by a number of medical issues including sepsis and peritonitis, a serious stomach infection.

Ms Syed continued: “There was a missed opportunity to provide antibiotics on September 15 from around 7.30am. If Sylvia had received these drugs by 8.30am on this morning she would have survived. Severe sepsis had predisposed and caused the pulmonary embolism.

“The pulmonary embolism, on balance, was not present at 7.30am to 8.30am on the morning.”

Mrs Lindsay was a long-term kidney patient and received daily dialysis treatment. Her widower Roy said that after surgery, he noticed that nursing staff did not seem to know how to properly check her dialysis bag. He said this was important because the colour of the liquid could be a clue to any infection.

Officials from the Royal Derby Hospital have been given 21 days to tell the Sylvia Lindsay

coroner what steps have been taken to prevent similar issues in the future.

Simon Tate, representing the hospital, said the trust was making sure nurses knew how and why they needed to check dialysis bags.

Ms Syed said: “I am deeply concerned by the nurses’ comment regarding record keeping and generally the standard of clinical record keeping in this case. I’m also concerned about the best practices in regards to inspecting dialysis bags.

“I was reassured very helpfully by Mr Tate that these matters were being looked at. This is not sufficient or satisfactory.”

Magnus Harrison, executive medical director at the University Hospitals of Derby and Burton NHS Foundation Trust, said: “The standard of care provided to Mrs Lindsay fell well below that which our patients and their families should expect and I would like to say to her family how extremely sorry I am that she did not receive the antibiotics she needed quickly enough.

“Early recognition and treatment of sepsis is a clear trust priority and we have made a number of key improvements since 2014 to ensure cases of sepsis are identified as quickly as possible.”

Mrs Lindsay’s husband Roy paid tribute to his wife following the outcome of the four-day inquest. The couple met through a friend in 1962 and wed two years later. They had two sons – Jason and Julian – and three grandchildren – Gabriel, Harriet and Jasmine.

“She was very strong, a very tough woman,” said Mr Lindsay. “She was never one to complain, very strongwilled and strong-minded.”