Grandmother died after “gross systemic neglect” at Isle of Wight hospital
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A Coroner has hit out at “gross systemic neglect” at the hospital where a grandmother died after medics failed to give her medication to prevent a fatal blood clot.
Dee Miller, 63, died after undergoing knee replacement surgery at St Mary’s Hospital on the Isle of Wight in July 2014.
She had developed a deep vein thrombosis after the surgery, which later blocked the arteries to her lungs, causing her death from pulmonary embolism.
At an inquest into Mrs Miller’s death, Senior Coroner Caroline Sumeray heard that Mrs Miller was at a high risk of developing deep vein thrombosis due to her age, weight and the nature of the surgery.
Despite these risks having been identified at a pre-operative assessment, no-one in the medical teams treating Mrs Miller acted upon that information, and no medication that could have prevented a clot was given to her following her operation. She was not given anti-embolism stockings to wear and had significant difficulties mobilising after the surgery.
The Coroner also heard that St Mary’s had no protocols in place around the prescribing of blood-thinning drugs following surgery.
Recording a narrative verdict, the Coroner noted the lack of medication given was a “gross systemic neglect in that the lack of it was not noticed by a number of clinicians and the prescribing of it was not the subject of any internal protocol.”
The Coroner also noted that this lack of medication was “likely to have contributed” to the deep vein thrombosis and subsequent pulmonary embolism which caused Mrs Miller’s death.
Mrs Miller’s widower Dave, 60, was represented at the inquest by BL Claims Solicitors and David Lang of College Chambers, and is now seeking to bring a claim against Isle of Wight NHS Trust.
Kym Provan, clinical negligence specialist at BL Claims Solicitors, said: “It is our view that Mrs Miller’s death would and should have been prevented if the right procedures were in place at St Mary’s Hospital.
“It should have been very obvious to the medical staff that there was a significant risk of deep vein thrombosis, and a proper assessment should have been carried out before the operation followed by appropriate treatment afterwards.
“There are very clear medical guidelines in cases where a patient is assessed to be at increased risk of thrombosis, including the prescribing of medication and the use of mechanical measures such as anti-embolism stockings.
“There is no evidence that this guidance was given consideration in Mrs Miller’s case, and it is the family’s belief that this was a failure that has resulted in tragedy.”
Mrs Miller had a total knee replacement in her right leg in 2006 but had suffered ongoing pain and problems since suffering a fall in November 2013.
By April 2014 her pain was worsening and she was placed on a waiting list to have a second knee replacement operation.
At a pre-assessment at St Mary’s Hospital in June 2014 it was noted that Mrs Miller was at high risk of deep vein thrombosis and it was noted that medical staff should make the decision as to what preventative measures should be put in place. Under the Trust’s own guidelines these would include anti-thrombotic medication and compression stockings following surgery.
No review of this pre-assessment was undertaken by medical staff and no effective preventative measures were put in place.
Mrs Miller had the operation on July 10, 2014, and died after suffering the pulmonary embolism on the morning of July 12th.
A Serious Incident Review completed by the hospital in March 2015 noted that the nurse who carried out the pre-assessment should have identified to the medical team the requirement for the prescribing of medication.
The review also highlighted that after Mrs Miller’s surgery, medical and nursing teams should have ensured that medication was prescribed according to guidelines.
However, by the time of the inquest on May 4 this year, the Coroner was still not satisfied that the hospital had put in place satisfactory measures, which would prevent such an error occurring again.
The hospital has until the end of May 2016 to present new information to the Coroner to show that appropriate procedures have been implemented.
Mr and Mrs Miller had been married for 34 years and lived together at the family home in Merstone, Isle of Wight.
They had three sons together and 11 grandchildren, and following Mrs Miller’s retirement as a taxi driver were looking forward to taking holidays together and enjoying family life.
Mrs Miller had been the main carer for her husband, who suffers from numerous health problems including diabetes, and has suffered three heart attacks.
Mr Miller said: “Dee had health problems but she loved life and her family, and we were looking forward to spending our retirement together. This has now been taken from us.
“What happened in hospital was catastrophic for our family and it is made worse because the mistakes were avoidable. Now I just want to make sure that lessons are learned and no other family has to suffer what we are going through.”
BL Claims Solicitors is now preparing a claim on Mr Miller’s behalf. The firm has more than 50 staff who specialise in personal injury, clinical negligence and travel claims. For more information see www.blclaims.co.uk
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