Westwood man's death 'hastened' by RUH mistake, inquest hears
8:57am Tuesday 16th October 2012 in By Will Frampton
The death of a Westwood man was ‘hastened’ after a mistake at Bath’s Royal United Hospital lead staff to calculate his blood sugar levels wrongly, an inquest heard yesterday.
Paul Coventry was diagnosed with acute pancreatitis at the hospital in January 2011 after complaining of pains over Christmas, and transferred to the intensive care unit (ICU)
The 56-year-old, who was clinically obese and had a history of alcohol abuse, also contracted pneumonia at the hospital and had surgery to drain fluid from his chest.
In the early hours of February 7 a bag of saline solution was replaced with a mixture of saline and dextrose sugar, attached to his arterial cannula used to remove blood samples for tests.
The inquest at Avon Coroner’s Court heard that Mr Coventry suffered brain damage after staff incorrectly detected the dextrose in his blood samples and administered insulin to lower his apparently high blood sugar, leading to hypoglycaemia.
He died on February 16.
Pathologist Dr Russell Delaney said the former garage owner died of multiple organ failure resulting from his pancreatitis and related ailments, but that the brain damage resulting from the mix-up hastened his decline.
“He was very ill due to the acute pancreatitis, which is most commonly caused by alcohol abuse,” he said. “In my opinion he would have eventually died anyway.
“But he never regained consciousness after the brain damage, and it would have affected his breathing and been a contributory factor to the time of his death.
“I would argue that it hastened his death.”
Mr Coventry’s partner Belinda Wells, who lives in their home in The Pastures, Lower Westwood, Bradford on Avon, was represented by a barrister at the inquest, as was the RUH trust, however she took to the stand as a witness.
She said he had been able to communicate somewhat even when sedated up until February 6, the day before the saline solution was changed incorrectly. The court also heard that he had written a personal message that day to his sister, Maria Reed.
“I went to see him the day before, I remember saying to him ‘I know it is hard but you have got to bear with it love because everything they are doing is for your own good,” she said.
“That was the last time I saw him conscious. When I went in the next day he was not responding to anything.”
Mrs Wells was told of the error by doctors several days later.
“We were devastated and completely shocked, I remember Maria saying whoever was responsible shouldn’t work in the ICU again,” she said.
“They had taken away all of Paul’s chances of getting better, no matter how ill he was, he wouldn’t have wanted to live like that if he had recovered.”
The inquest also heard from consultant anaesthetist Andrew Hartle, of St Mary’s Hospital in London, who carried out an investigation last year for Avon and Somerset Police.
He said the saline/dextrose mix was unusual and chiefly used in paediatric medicine, and that staff may have read ‘saline’ on the bag without acknowledging the sugar.
The police investigation was dropped as prosecutors could not find enough evidence of who was responsible for the error.
Coroner Maria Voisin adjourned the inquest until today when staff from the hospital, including staff nurses Rosita Chan and Caroline Liywali, who also both have representatives to cross-examine witnesses, are expected to give evidence.