A GRIEVING family wept as they heard a hospital admit that it had failed in its care of a cancer sufferer.
Just 18 days after he was diagnosed with a rare and aggressive form of bladder cancer Nigel James died while being treated at Southampton General Hospital.
An inquest into his death heard how there had been a catalogue of problems that culminated in a failure to diagnose a blood clot from which the 67-year-old from Hythe eventually died.
The main complaint centred around the apparent failure to administer a drug called Heparin prescribed to prevent blood clots.
Poor record-keeping meant it was impossible to know why this hadn’t happened as Mr James was displaying clear symptoms that he was suffering from the condition, the inquest heard.
His distraught family wrote a 47-page letter of complaint which prompted an internal investigation, the inquest was told.
The subsequent report identified 36 different failings by the hospital during Mr James’ stay.
- No assessment carried out into the risk of Mr James suffering a blood clot, despite it being a national guideline
- Inadequate recording of vital signs and pain management
- Failure to adequately provide food and drink
- Lack of communication between medical staff, the patient and family over treatment
- Poor standard of patient care which in one instance led to a “full scale shouting match on the ward” by a nurse
Giving evidence, author of the report associate medical director for patient safety David Weeden concluded: “The review has highlighted significant lapses in the medical and nursing care and failed to meet the high standards of [the hospital].”
He said due to a lack of medical notes it was “impossible to know for sure” why the Heparin drug was not given but it did carry a risk of potential side effects including causing bleeding.
The hearing also heard from consultant Charles Lockyer, who had been Mr James’ surgeon.
He said: “We failed this man’s family, and he had a terrible experience during his stay.”
Mr Lockyer said it had always been the longer term aim to stabilise Mr James’ condition so he could withstand chemotherapy.
However, he said it had appeared opportunities to diagnose the blood clot had been “missed” by junior doctors.
Mr Lockyer said the case had been a “big driver” for improvements within his department that had been made since Mr James’ death.
Coroner Keith Wiseman said he would record a verdict next month when he had had time to consider all of the evidence.
WHAT THE HOSPITAL SAID:
SOUTHAMPTON General Hospital said the extensive probe that was carried out in the wake of Mr James’ death had found a series of failings in his care.
Mr Weeden said the inquiry had found a number of areas where lessons had been learned, systems were shownto be inadequate and in some cases errors of judgement had been made.
The report did conclude that even if the diagnosis had been made, it would not have altered Mr James’ prognosis.
However, his family say it prevented him from having a dignified death as he was excluded from knowing what was happening to him.
Wide scale changes have since been made including revamped medical records, better training for staff when communicating with families and improved levels of risk assessing patients for blood clots.
Mr Weeden said: “A lot of work has been put in across the whole trust about reminding everybody that patients have the right to be included in decisions that are concerned with important elements of their care.”
He added: “We are in a caring profession and we should care."
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