Neglect contributed to hospital death - coroner

Neglect contributed to the death of a disabled woman while in hospital, a coroner concluded.

Kelly Stevens, who had profound learning and physical disabilities, died at Worcestershire Royal Hospital in January.

In his inquest, coroner David Reid said he found multiple concerns with her care and concluded she died from complications associated with an "excessively low and unrecognised sodium level".

The NHS trust running the hospital apologised unreservedly to Ms Stevens' family and said the events "fell a long way" below its standards.

Ms Stevens was admitted to the hospital on 28 December with a swollen abdomen and concern about a feeding tube and staff diagnosed her with "likely pseudo-bowel obstruction".

She was prescribed intravenous fluids and a plan was made for her to undergo further investigation but her intake of the fluids was "not properly recorded" and her electrolyte levels "were not monitored", the coroner wrote in his report.

"No doctor providing care for Ms Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes," Mr Reid added.

On 3 January, Ms Stevens suffered a seizure due to her very low sodium level "which had not been recognised" and she developed pneumonia before she died later that day.

Action should be taken to prevent future deaths, Mr Reid said in a prevention of future deaths report addressed to the trust's chief executive.

"No one consultant was in overall charge of her care which meant that the issues identified in this case were not picked up on," he wrote.

Mr Reid said it was expected consultants would liaise would each other but "that did not happen in this case".

In a statement, Worcestershire Acute Hospitals NHS Trust said it had carried out a full investigation and a "comprehensive action plan" had since been put place including "targeted education" around prescribing and extra oversight to try to avoid future events.

"Ms Stevens’ family have been kept updated on our investigation process throughout and the full set of actions we are taking as a result will be shared with them," Sarah Shingler, chief nursing officer added.

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