Nurse suspended as RUH launch probe after Westwood man's death
12:52pm Thursday 25th October 2012 in News
Grieving Belinda Wells says hospital staff let her fiancé down after an inquest heard that he died because of fatal blunders in his care.
Paul Coventry, 56, of Lower Westwood, near Bradford on Avon, was taken into intensive care at the Royal United Hospital in Bath in December 2010 after complaining of stomach pain over Christmas.
He died just after midnight on February 19 last year from multiple organ failure resulting from pancreatitis and related ailments.
But a seven-day inquest at Avon Coroner’s Court 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.
He suffered brain damage after staff administered insulin, leading to hypoglycaemia and nurse Rosita Chan has now been removed from duty as the hospital carries out a second internal investigation.
Ms Wells, 53, said: “Paul was let down by the standard of care at the RUH at a time when he was at his most vulnerable.
“When I was told by the doctors that there’d been an error and this had caused Paul brain damage, I was knocked to the floor, devastated, and in disbelief.
“I realised there was no chance Paul could recover and the grief was impossible to bear.
“I remember leaving the hospital wracked with sobs. I knew grief and shock on a level I’d never experienced before in my life.
“Paul’s brother and sister and I had agreed that he wouldn’t have wanted to live with such severe brain damage, he hated to see anything suffer, and when the tests confirmed it, we agreed to switch off his life support on the 18th.
“We didn’t know if he would recover or not, but he deteriorated and died just after midnight the next day. “I will never forget that moment.”
At the conclusion of the inquest on Tuesday, Coroner Maria Voisin recorded a verdict of accidental death contributed to by neglect on the part of the RUH.
Intensive care nurse Chan gave evidence at the inquest, admitting not carrying out the proper checks on a saline bag she took to Mr Coventry’s bedside on February 6.
Ms Wells said: “I am surprised the RUH has chosen to suspend this nurse now, obviously the investigation they carried out last year was not thorough enough.
“They had ample warning that this might happen, both from a report published in 2008 and I was shocked when I discovered the same thing happened in December 2010.
“The diligence and persistence of my barrister Richard Mumford and the police team led by DC Salter has resulted in the truth coming out about this tragic blunder.
“I feel the hospital has learned a great deal from this tragedy, and it is certainly a safer place to be treated than before Paul died.
“But we who loved Paul will live with this always, and forever miss him and wonder what might have happened had a different nurse been on duty that night.”
Ms Wells met Mr Coventry, a former Bath garage owner, in 2002 while out with a friend in Bath, and they moved in together in Westwood in October 2003.
The pair, who together ran a kitchen and bathroom design business, were engaged in November 2005, but had to put their wedding on hold for financial reasons.
However, when Mr Coventry went into hospital they still hoped to wed in the near future, and planned to move to Cyprus. They had no children.
Summing up the coroner said she would write to the Department of Health to inform them of the incident, and to the RUH to “review personnel quality in relation to management of staff, including bank staff”.
An RUH Trust spokesman said the hospital had changed equipment to make saline bag labels more visible, introduced an improved care checklist for every patient, and a requirement for senior nursing staff to double check equipment.
He added: “We would like to extend our sincere condolences to Mr Coventry’s family at this difficult time.
“A similar incident in December 2010 did occur and fortunately on that occasion was detected very quickly and caused no harm to the patient.
“However the Trust took immediate action to strengthen procedures. We recognise that despite these early actions the mistake sadly repeated itself.”