Missed medication in hospital contributed to woman’s death

Date: Tuesday 13th February 2018

A WOMAN who died from a blood clot on her lungs probably suffered further clotting as a result of a missed dose of blood thinning drugs in hospital, a coroner has concluded.

Marlene Oxby, of Catterlen, was 69 when she died at the Cumberland Infirmary, Carlisle, on 25th March last year, following a cardiac arrest.

Assistant coroner for Cumbria Dr. Nicholas Shaw said that had efforts to revive her succeeded, she would never have been the woman she once was and concluded that, despite missed opportunities to intervene, she died of natural causes.

At an inquest at Cockermouth, the coroner heard from her partner Terence Boyd that, while she had been a lifelong smoker and suffered from chronic obstructive pulmonary disease (COPD), she had been fit enough to walk their dogs just two weeks before her death.

However, she began feeling breathless and an ambulance was called when she also began getting chest pain. Paramedics referred her to her doctor, who awaited her already scheduled appointment at the respiratory clinic.

She was later admitted to hospital and diagnosed with a pulmonary embolism (clot to the lung).

Staff nurse Judith Hodgson said Mrs. Oxby was moved from an injectable anticoagulant to an oral tablet, but there was none of the correct dosage on the ward. It was ordered from the pharmacy, but the doctor was not informed of the missed dose to see if alternative medication should be administered. Ms. Hodgson said she asked junior doctor Cheryl Walker to have a look at Mrs. Oxby, but the doctor “clearly couldn’t be bothered”.

However, in her statement, Dr. Walker claimed not to have been asked to review Mrs. Oxby’s condition, but had checked in on her anyway, and found her to be sleeping and of normal colour. She said she had not been told of an elevated MEWS (modified early warning score) from routine observations.

At handover to a new shift, another staff nurse, Katie Armstrong, said she was unaware of Mrs. Oxby’s missed medication, which Ms. Hodgson said she had instructed should be given at 8pm. She also did not escalate another increasing MEWS to a doctor when Mrs. Oxby’s heart rate was increased and oxygen levels decreased, saying she had not been aware of the previous one and that since Mrs. Oxby had just been out of bed, she put it down to exertion and decided to monitor her again within an hour.

This actually happened within 15 minutes, but Mrs. Oxby then deteriorated very quickly and suffered a cardiac arrest. A crash team was unable to revive her.

Cumberland Infirmary matron Neil Anderson, who was asked to carry out an investigation following Mrs. Oxby’s death, which was flagged as a serious incident, said numerous actions had been taken as a result, including updated training on the importance of escalating increased MEWS and correct record keeping. However, he said the one which it was hoped would have the biggest impact was a move towards electronic recording of observations, which would remind staff when they needed repeating and what actions should be taken as a result of the score.

He said the scheme was already being piloted and he expected it to roll out within 2018.

In his conclusion, Dr. Shaw said it was his belief that Mrs. Oxby had suffered further embolism as a result of her missed medication and added that the junior doctor’s response at being asked to look at the patient was not satisfactory.

“She received a single half dose of anticoagulant in the last 24 hours of her life. It is my thought that she was having a further embolism and she had a cardiac arrest,” he said.