Hospital 'errors' over death of Gran
The family of a pensioner spoke of their relief after a four-year fight to learn the truth about her death revealed blunders by doctors.
An inquest into the death of 89-year-old Lillian Elliott heard that her family were originally told that she had died of natural causes.
But now a coroner has ruled that an adverse reaction to medication which was missed by doctors at Wigan Infirmary contributed to her death.
Mrs Elliott's granddaughter Jill Orrell, of of Staplehurst Close, Hindley Green, who has made 26 requests for an inquest during the past four years, said: "We have been proved right and are relieved.
"My nan deserved this. The past four years have been filled with anger but now we can get on with our lives and grieve in peace."
During the hearing at Bolton, 13 witnesses gave evidence concerning Mrs Elliott's care and revealed a catalogue of errors.
After being taken to hospital with a minor head injury, the grandmother-of eight-and great-grandmother-of-nine was admitted on to a ward for observation at the request of her family.
But 17 days later in December 2003, she died of heart failure after developing heparin induced thrombocytopenia (HIT), a rare condition triggered by an adverse reaction to anti-coagulant medicine Clexane.
The court heard how after being administered the drug to prevent blood clots developing as she lay in bed, Mrs Elliott was not monitored adequately for six days, during which time her platelet levels plummeted and she developed a gastrointestinal haemmorage. An immediate blood transfusion was required – but it was not given until 48 hours later.
Geriatrics expert Professor Ken Woodhouse, whose report finally pursuaded coroner Jennifer Leeming to hold an inquest, said: "A really close eye should have been kept on her, but it wasn't. Her prognosis was poor but it wasn't unrecoverable.
"As a result, I think HIT significantly contributed to her death."
Expert haematologist Dr Vanessa Martlew agreed and said Mrs Elliott's extremely low platelet count should have prompted a phone call and immediate treatment.
Witnesses included five consultants, each of whom did not realise Mrs Elliott had developed HIT. They all denied direct responsibility for her care despite having treated her.
Due to poor communication, plus medical notes being wrongly transcribed, false information was passed from one doctor to the next, resulting in a failure to carry out necessary blood tests and the patient's death certificate being incorrect.
Pathologist Dr Stephen Mills had recorded that a contributory factor to death was a fractured neck of the femur, which he lifted from Mrs Elliott's inaccurate notes. But a total hip replacement carried out 10 years earlier, meant such a fracture was impossible.
Mrs Orrell also questioned why severe bruising on Mrs Elliott's legs, a result of HIT, was never mentioned in his report, and revealed that due to her grandmother's wrist band having fallen off in the ward, the family suspected that the wrong body may have been examined.
Dr Mills said he had never before seen a case of HIT and believed the bruising to be the result of a fall.
Coroner Leeming stated that because of Mrs Orrell's dedication, lessons would be learned, including changes to ensure improved communication in hospitals. She also revealed she would be reporting Mrs Elliott's adverse reaction to Clexane to the relevant regulatory agency.
She recorded a narrative verdict, concluding: "She died of naturally-occurring cardiac disease, to which complications of anti-coagulant therapy and acute diarrhoeal illness contributed."
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Tuesday 07 February 2012
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