THE family of a Stratford-upon-Avon woman who choked to death on porridge alone in her bed at Warwick Hospital believe she should still be alive today.
Margaret Walker, of Hathaway Green Lane, was 86-years-old when she died after a nurse gave her a spoonful of porridge and went on her break.
At an inquest last week, the coroner asked for reassurances that lessons had been learnt from her death, which made him “uncomfortable” over the quality of communication at Warwick. He has written formally to the health trust which runs the hospital.
David Walker, her son, told the coroner that the poor standards of care at the hospital led both “directly and indirectly” to his mother’s death. “Directly, I think if she had been responded to in that 15-20 minutes by another nurse she would not have died,” he said.
Margaret died in her room which contained suction equipment that could have been used to save her life.
“Indirectly, her general state of health deteriorated during her stay in hospital because she wasn’t particularly well looked after,” said Mr Walker.
In a statement on behalf of the family, he said: “We are very disappointed to find out the extent of the poor nursing care and lack of dignity and respect shown to Margaret.”
Admitted to hospital as an emergency after a fall, Margaret was then diagnosed with breast cancer after a routine examination.
Just after 9am on 2nd February she choked to death on Beaumont Ward after nurse Geraldine Pettipher gave her a spoonful of porridge and then went on her break.
Ms Pettipher, a nurse from an outside agency providing shift cover, said she was told to go on her break by Aurora Gherman, a senior Warwick Hospital nurse. But Ms Gherman said that she would not have told anyone to go on their break that early in the shift.
Both were worried about Margaret just before her death, the inquest heard.
Before breakfast Ms Gherman had called for a doctor to come and look at her, and Ms Pettipher said she became concerned after feeding Margaret the porridge.
“I heard her swallow it, and as soon as she did she be-came pale and her breathing became irregular,” she said.
After seeking out Ms Gherman, both nurses returned to the room where neither considered Margaret was at risk of choking or in respiratory distress.
It was then that Ms Pettipher went on her break and Ms Gherman left the room.
By the time a doctor arrived, Margaret had died.
The family and the coroner were both concerned about the nurses’ different accounts and the catalogue of communication errors that arose during the inquest.
Ms Pettipher said she was told that Margaret’s cancer had spread, however a post-mortem examination reveal-ed no signs of this. This inaccuracy concerned Mr Walker as his mother had been labelled a ‘do not resuscitate’(DNR) patient.
He said: “Ms Pettipher was told it had spread, and that must have contributed to any decision not to resuscitate.” He was surprised to hear that the nurses thought she was more poorly than she actually was, but both nurses confirmed that DNR orders do not apply to choking.
Mr Walker said hospital staff did not seem to know basic information about Margaret and her condition. “We are not sure if she was assessed properly, most of the nurses did not understand that she had hearing difficulties,” he said.
The family provided two hearing aids and medication to the hospital upon her admittance, all of which was lost.
At the inquest, Ms Pettipher, who works in hospitals up and down the country as an agency nurse, said she had previously found difficulties getting a doctor on Beaumont Ward, and that she was never properly inducted onto the ward.
“If I work in an area I am normally given an induction, shown where the crash trolley is,” she said.
When the coroner asked if her experience at Warwick Hospital differed to that of others, she said “Yes, it did differ”.
After recording a narrative verdict at the inquest last week, Warwickshire assistant coroner David Clark wrote formally to South Warwickshire NHS Foundation Trust for assurances that lessons had been learnt. He was particularly uncomfortable with the quality of communication between agency nurses and hospital nurses.
The trust confirmed that a full investigation had been conducted into Mrs Walker’s death. A spokesperson said: “The trust’s investigation found that some elements of record keeping should have been better and this is something that the trust has placed a lot of emphasis on with our nursing teams.”
The trust was given 28 days to provide the coroner and Mrs Walker’s family with evidence of the improvements that have been made to their induction process for agency nurses.
On behalf of the family Mr Walker said: “Margaret was a loving mother and grandmother and is sadly missed.
“The family are pleased the inquest has finally been concluded and note the coroner has written formally to South Warwickshire NHS Foundation Trust regarding various specific procedures at Warwick Hospital.”
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