Paperwork problem in hospital meant man died in agony
PUBLISHED: 19:30 25 June 2008 | UPDATED: 13:22 06 May 2010
A PROBLEM with hospital paperwork meant that a man died in agony surrounded by distressed members of his family attempting to relieve his suffering. Cecil Marsh, aged 82, of Batchwood Drive, St Albans, died on October 23 last year at Watford General Hospi
A PROBLEM with hospital paperwork meant that a man died in agony surrounded by distressed members of his family attempting to relieve his suffering.
Cecil Marsh, aged 82, of Batchwood Drive, St Albans, died on October 23 last year at Watford General Hospital, an inquest heard this week.
The former storeman, who had been a Merchant Navy seaman during the Second World War, was first diagnosed with bladder cancer five years ago.
Mr Marsh's daughters and a son were at the inquest to question ward staff about why their father's pain relief had failed to control his suffering at the end of his life. They had witnessed his distress as he cried out in pain.
Ward sister Jackie Dick apologised to the family explaining that Mr Marsh should have been fitted with a syringe driver so that morphine was steadily pumped into his system.
But she said: "Due to a problem with paperwork a doctor had failed to write up the correct equipment. "
That meant that Mr Marsh had a manual pump fitted which he could not operate himself and relied on staff and family members to administer it. Repeated attempts by family and staff to remedy the situation themselves failed.
Mr Marsh had gone into hospital on October 11 and following a CT scan on October 19 it was decided to carry out an exploratory operation.
But as soon as he was given the general anaesthetic he started to vomit bile. and later developed pneumonia as a result of some of the acid contents of his stomach contaminating his lungs.
Coroner Edward Thomas gave a narrative verdict saying Mr Marsh died from aspiration pneumonia after an operation to investigate the extent of the bladder cancer which had in fact spread to his lymph nodes.
He said he was saddened to hear that the family had to remember their father's final hours in such a terrible way especially as Watford General was among the top hospitals in the country for palliative care.
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