Neglect contributed to Westwood man's death
An inquest into the case of a patient who was given the wrong saline solution at Bath's Royal United Hospital has heard that neglect contributed to his death.
Paul Coventry, 56, from Westwood, near Bradford on Avon, died on February 19 last year from multiple organ failure resulting from pancreatitis and related ailments.
The inquest at Avon Coroner’s Court in Flax Bourton heard how a mix-up which saw a bag of saline solution replaced with a mixture of saline and dextrose sugar hastened his death after it led staff to miscalculate his blood sugar levels.
Mr Coventry, a former Bath car dealership owner, suffered brain damage after staff reacted to the dextrose in his blood samples by administering insulin to lower his apparently high blood sugar, leading to hypoglycaemia.
Coroner Maria Voisin summed up the evidence she had heard before recording a verdict of accidental death contributed to by neglect.
She said she would be writing to both the Department of Health and the RUH with her findings.
Ms Voisin said: “There were a number of failures, including wrong fluid being used.
“This contributed to his death as there was inaccurate blood readings, which led to insulin being administered.
“In reviewing all the evidence before me I have reached a verdict of accidental death contributed to by neglect.
“I will be writing to the Department of Health in regards to the wrong fluid being used.
“I will also be writing to the Royal United Hospital to review personnel quality in relation to management of staff, including bank staff.”
During the seven-day inquest Ms Voisin heard evidence from a number of doctors and nurses, including pathologist Dr Russell Delaney, who said the brain damage resulting from the mix-up “hastened” Mr Coventry’s death.
Nurse Rosita Chan gave evidence, admitting she had not followed the proper procedure of checking the contents of the saline bag, but used her rights under inquest rules to decline to answer some other questions.
Mr Coventry’s family were present during the inquest, including his partner Belinda Wells, with whom he lived at Lower Westwood.
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