Cannock woman died of rare blood clot - inquest

Nov 6 2008 By Lynn Grainger

A Chase pensioner died in Stafford hospital after contracting an ‘extremely rare’ form of blood clot which remained undiagnosed until after her death.

And, a coroner heard, a mix-up with notes had led staff to almost treat Vivian Edwards with a drug to which she was severely allergic and which had left her blind in the 1970s.

Mrs Edwards, 90, was a patient on Ward 11. She had been admitted there after being taken to A&E following a collapse. The pensioner had also recently broken her right leg which was in a cast.

South Staffordshire Coroner Andrew Haigh was told Mrs Edwards had been diagnosed with a bowel condition in 2006 and had been admitted to hospital on two previous occasions after suffering bleeding from the bowel.

Mr Haigh heard Mrs Edwards, of Foster Avenue, Hednesford, had subsequently suffered a heart attack on both occasions as a result of the bleeding.

Following her final admission to the hospital she began to show signs of infection at the beginning of April and was put on a course of antibiotics. It was also noted her leg was healing poorly.

On April 10 tests suggested Mrs Edwards was developing an infection in her blood and her antibiotics were changed.

By April 21 her condition was described as ‘serious but stable’. She was given further antibiotics and more tests were planned.

She was monitored on a daily basis, showed some signs of improvement, but died on Ward 11 on May 27.

Gastroenterologist Dr Ray Matthew explained it had been difficult to treat Mrs Edwards because of her fragile health. He said a camera could not be inserted into her bowel in an attempt to find the source of the bleeding because of the risk of a further heart attack.

And he said the source of the growing infection could not be identified, despite a number of tests.

Pathologist Dr Stephen Harris examined Mrs Edwards’ body. He said the cause of death was heart failure brought on by infection following the fracture of the right leg.

He explained it was only during the postmortem that the source of Mrs Edwards’ infection was discovered - it was in a blood clot in her right leg.

“This is the first time I have seen it (an infected thrombus) in 20 years. There must have been bacteria within the blood stream that got trapped,” he told the coroner.

Dr Harris said Mrs Edwards’ heart showed signs of disease and that her general immobility following the fracture and poor nutrition had ultimately affected the heart muscle.

The pathologist also said that though Mrs Edwards was known to suffer with Crohn’s disease (which causes inflammation of the gut) he saw no evidence of it being ‘active’. However, the cause of her bleeding still remains unresolved.

At last Thursday’s (October 30) inquest Mrs Edwards’ niece Jean Burgundy-Roberts raised concerns about her aunt’s treatment on Ward 11.

She said if she had not been present on one occasion Mrs Edwards would have been given Gentamicin, the drug which had left her registered blind 30 years before.

However Dr Matthew said that, when asked, Mrs Edwards had denied being allergic to any medication. He also told the coroner the mix-up could have occurred because Mrs Edwards had two different sets of notes, each of which had a different date of birth and so had not been ‘married up’ by the computer system.

Mrs Burgundy-Roberts said she had also raised other care issues with staff over hygiene, communication with family members, her aunt’s mobility, food, pressure sores and the swelling of her broken leg.

South Staffordshire Coroner Andrew Haigh recorded a verdict of accidental death.

He said the infection in the clot had been ‘extremely rare’ and concluded: “We have heard Dr Matthew explain that the likely explanation for Mrs Edward’s being given the drug [Gentamicin] is the dual notes. I hope that is something that is looked into and picked up on for the future. I hope it is something good that can come out of this.”