NHS Trust admits failings after death of patient may have been avoided
HOSPITAL bosses have admitted serious failings following the death of a woman that could have been prevented.
Claire Harry, 36, died from complications of diabetes shortly after being admitted to the Royal Cornwall Hospital in Truro on September 27, 2010, with a chest infection.
An inquest on Monday heard her dangerously low blood sugar levels went unnoticed because she was not being monitored as regularly as she should – every two hours – since a similar problem two days before.
Her state was only being observed every six hours on the night she slipped into a coma, which was cited as a mistake.
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Miss Harry was visited at 6.20am by a healthcare assistant, who found her "peacefully asleep" and was unable to rouse her to take a planned reading, but did not alert anyone else to the situation.
Hyder Hussaini, a consultant who had cared for Miss Harry since 2000 and suggested insufficient or inadequate training could have played a part in the death, said the lack of action was a "major error of judgement".
The inquest heard Miss Harry's death might have been prevented had her blood sugar levels been taken by the assistant at the time specified. Miss Harry was found in a critical condition at 7.20am, having already suffered irreversible brain damage, later developing bronchopneumonia. She died on October 13.
The inquest in Truro heard Miss Harry, from Penzance, had not been seen by a diabetic specialist, and the inquest noted confusion over appropriate provision of care, detailing her blood sugar levels and failures by staff to appreciate the significance of her unstable condition three days earlier.
Cornwall Coroner Emma Carlyon gave a narrative verdict, stating: "Claire Louise Harry died from bronchopneumonia due to brain damage caused by the hypoglycaemic event on September 30 due to diabetes, which was not recognised or treated in time to avoid death."
Her father Clive Harry said he and his wife Monica had expected her to receive speedy treatment and return home. Instead, three days later they were called to the hospital to find her in a coma.
"When we had the phone call we didn't know what had gone on," said Mr Harry.
"We were numb – we couldn't do anything.
"We couldn't understand it. We were just in shock. That's what I can't understand; why didn't she wake her up?"
His daughter had faith in the hospital after attending regularly for medical problems experienced throughout her life, her father said.
"Claire had so much trust for the ward and the staff," he said. "She saw them as more of a family."
Lezli Boswell, chief executive of the Royal Cornwall Hospitals Trust (RCHT), wrote to the family earlier this year admitting an "unacceptable failure" resulting in "a delay in commencing appropriate treatment. Had such treatment been implemented as it should, Claire's condition was likely to have been treatable and she would not have died when she did."
The RCHT has admitted legal liability and outlined changes implemented following her death, including an additional nurse on Carnkie Ward and more staff training.