Watford General Hospital were ‘not to blame’ for St Albans patient’s death, inquest hears
A series of issues at Watford General Hospital did not cause the death of a schizophrenic patient, an inquest heard on Tuesday (8).
Herts coroner Geoffrey Sullivan ruled that St Albans resident Lynne Ramsay died from the side effects of her medication, which proved fatal in the early hours of October 3 2014.
The inquest aimed to establish whether she could have been saved had she received proper care at Watford General Hospital following reports that there had been a series of issues.
The 58-year-old, who was diagnosed with schizophrenia in 1990, had low sodium levels in her blood, which resulted in an abnormal pressure gradient in her brain - a condition called cerebral oedema.
She later went into cardiac arrest, and was pronounced dead at Abbey Lodge Care Home in London Colney, despite attempts by staff and the ambulance service to revive her.
Mrs Ramsay had been admitted to hospital via ambulance at about 6pm the evening before (October 2) following difficulty breathing and underwent multiple tests. She was discharged at 9.50pm.
Evidence at the inquest revealed that Mrs Ramsay had been discharged before all of her test results came back; crucially one which revealed that the sodium levels in her blood were fatally low.
A change to the coding on the computer system meant that the doctor looking after her was led to believe that all of her results had been released, so discharged her.
Soon after, at about 10.15pm, a biochemist attempted to phone the A&E department to speak to the relevant medic about the test, but the call was ‘hung up.’
Dr Matilda Ralph, who carried out the toxicology report, highlighted during her evidence that the biochemist ‘went above their duty’ by proceeding to call about ‘four or five times’ in an attempt to contact the department.
It was ‘some time after’ at 1am when the biochemist eventually reached a nurse who told the relevant doctor about the results.
A call was then made to Abbey Lodge asking for them to call an ambulance but by this time Mrs Ramsay was found collapsed on her bathroom floor.
Evidence from three doctors was given at the hearing alongside a report by clinical negligence expert Dr Stephen Metcalf, which was read to the court.
Both the report by Dr Metcalf and the evidence given by Dr Ralph demonstrated that little could have been done to save Mrs Ramsay’s life because her symptoms were too severe - even if she had remained in hospital.
The coroner ruled that despite the series of issues with Mrs Ramsay’s care at Watford General Hospital, the medical evidence provided suggested that her condition would have been fatal regardless.
Passing a verdict that Mrs Ramsey died as a result of the chronic side effects of the necessary medication, Mr Sullivan said: “Despite the confusion caused by the so-called upgrade to the computer system that meant a doctor thought she had received the [all the] results when she hadn’t, and the difficulty the pathology department had to get someone in the A&E department to take responsibility for those results, it would appear from the evidence that this didn’t contribute to Mrs Ramsay’s death.”
Mr Malla, who appeared at the hearing on behalf of the West Hertfordshire Hospitals NHS Trust, apologised to the two family members present.
The inquest heard that staff were made aware of the issues with the computer system immediately, and changes were made within the month following Mrs Ramsay’s death.
A designated phone line and protocol was also put in place the day after her death to ensure no vital reports were missed again.
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