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Pensioner dies in hospital blunder after nurses wrote medical notes on paper towels
Last updated at 13:22pm on 14.11.07A hospital patient died after nurses wrote vital medical notes on paper towels and post-it stickers.
Patricia Prowse, aged 78, went into hospital for a minor operation but died after a succession of blunders left her without essential anti-stroke drugs for three days.
Confused nurses tried to check the prescription with doctors but queries left on her drug sheet were lost and pagers never answered.
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Tragic: Pensioner Patricia Prowse died after nurses wrote vital medical notes on paper towels and post-it stickers
The sprightly grandmother died a day after collapsing over her breakfast at Derriford Hospital in Plymouth, Devon, which has now admitted a catalogue of errors and apologised to her family.
She had been on the anti-clotting drug warfarin before going into hospital but was taken off it to prevent her bleeding during a minor operation to drain blood and fluid from her leg.
Doctors prescribed another anti-clotting drug called Clexane but she received only one injection of it.
She should have had a similar jab for the next three days but three different nurses were unclear about the dose and left notes on the drug sheet to try to clarify the position with doctors.
One of the notes was written on a paper towel normally used to dry hands after washing and two others were on post-it stickers.
The bungles came on top of a series of other errors in which Patricia was given physiotherapy intended for a patient in the opposite bed and sent for a scan with the other person's notes.
Her family also noticed that a drip was switched off for four hours 15 minutes on the day before she died.
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Bungling: Derriford Hospital in Plymouth, Devon
A coroner ruled that the errors contributed to her death as he recorded a verdict of death by natural causes.
A post mortem found she died of a pulmonary embolism, pneumonia, a stroke and heart disease on September 1, 2005, eight days after going into hospital.
Widow Patricia, from Plymouth, suffered a minor fall three weeks before going into hospital and needed a minor operation to remove a swelling from her shin.
Assistant deputy Plymouth coroner Mr Rob Newman said the chances of Patricia having a stroke would have been reduced by two thirds if she had been given the proper medication.
He ruled there had been neglect but it was not gross neglect and he was satisfied the hospital has now tightened procedures.
He said: "In the course of this inquest a number of failures on the part of those entrusted with this patient's care have been identified.
"A number of failings relate to the recording, or not recording of information. There was not good communication between the nursing staff and doctors and part of that was the way in which messages were passed.
"It does not appear that on any of the occasions when nurses bleeped doctors to get advice about Clexane these were responded to while they remained on duty, even though in most cases that amounted to a number of hours.
"The other way messages were passed was through notes. Post-it labels were used twice, what seems to be a scrap of paper once, and a paper towel was used on another occasion.
"This was an absorbent paper towel. I asked if it was possible to write on it and was assured it is and it appears this was not the first time it happened.
"There was nothing to indicate the name of the patient or the date or time of the messages.
"Significantly, none of the four messages are available even though the investigation started very shortly after the patient's death.
"It is important that matters like this are dealt with urgently and effectively and I have to say that did not happen in this case and that is why a number of the questions about giving Clexane went unanswered.
"I conclude that the omission in failing to give this drug did make a contribution to the death.
"I would conclude however, that the failure to give it on three nights cannot be regarded as a gross failure because it is clear the patient was being given medical attention."
After the case Patricia's granddaughter Kelly Day, aged 29, said: "The whole family is disgusted with the way my Nan was treated by the hospital.
"There was a lack of staff because it was a bank holiday weekend and the communications just broke down.
"Her treatment was very poor and we just hope the hospital have learned so other families do not go through what we have.
"People should be able to go into hospital for a minor operation and come out alive rather than dying like this."
A spokesman for the hospital said: "We would like to reiterate our sympathy and apologies to the family of Mrs Prowse.
"Mrs Prowse was not given the medication she was prescribed. This is simply not acceptable and we must apologise to her family for failing their mother and grandmother and the subsequent distress this has caused them.
"As soon as we discovered that the care had been less than satisfactory, we alerted Mrs Prowse's family and they came to meet with us so we could explain to them what had happened.
"We then carried out a full investigation and we have since met with them to go through the findings and detail what measures were being put in place to try to ensure that the mistakes that were made in this case will not be repeated."
Reader views (10)
Last year our mum suffered as she spent the last week of her life in St Thomas' Hospital, she had lung cancer and was admitted after suffering a seisure. She should have been taken to a hospice but was refused as we were told she was not ill enough. Instead she lay in a non cancer care ward with inexperienced staff who reduced her morphine and tried to get her on her feet. We watched her suffer in pain, waiting all day and night for a doctor to see her. Our precious mum did not deserve to end her life in this way. She was such a happy person and loving mum and nan, we shall always treasure those memories but we are so hurt by the way she was treated in her last days of her life. There are so many cases like ours it's about time that something was done about it. The lottery should fund the NHS and employ more doctors and nurses with the wages they deserve.
- Lesley, London
To lose a loved one is always very very sad but to lose someone like this is in my opinion can only be described as criminal.
- Mike, Bedford, England
I'm an ex nurse and the standard of nursing care I've seen in the NHS is absolutely disgraceful. There is no more discipline, no Nursing Officers, No Matrons. The younger nurses don't seem to care that their sole responsibiity is supposed to be towards the welfare of the patient. Most of them seem to think it's beneath them to feed a patient or fetch a bedpan, let alone make a bed! I watched the disgraceful nursing care of an aunt of mine who was on steroids. She was being pumped full of liquids but nothing was coming out the other end, no-one had even noticed for days. It wasn't until I went over and explained to them the dangers, that they got a doctor immediately who took down the drip and took her water away. It was too late by then as her lungs had filled with fluid and she died.
- Sue, Orfpington, Kent
I feel for the family. To watch someone you love so much be treated this way is awful. Our mum passed away in hospital just over a year ago now from lung cancer. The last week of her life in an NHS hospital was dreadful. On one ocassion a nurse made numerous calls for a doctor to come and see mum as she was in so much pain and needed a prescription for morphine. We waited for a doctor all day with mum crying out in agony. When she finally attended to our mum later that night she told us that she had been busy all day dealing with patients that were more serious than mum. I understand they are busy and short staffed but to leave someone in pain all day is not acceptable. We have so many lovely memories of our happy little mum and nan. But memories of the last week of her life will hurt us forever.
- Debbie, London
This is just a terrible symptom. The underlying cause remains the poor management/training of the resources available to the NHS as a whole. And this in turn is a result of the unpredictable political winds used to direct those managers. It's taken years to ruin the NHS (this Government isn't solely to blame) and it may never be fixed.
However, I heartily respect those in the NHS that truly try to overcome the huge incumberances in their path and make a difference on a daily basis.
- Harry Flower, Northolt,UK
When I read of this poor woman's fate my heart stopped. It took me back to St Thomas's, London, early summer this year. A friend had meed admitted and I popped over to see him. While I was with him, a nurse came to take his vitals and I was shocked at her behaviour. She was busy admiring my sandals, slappled the cuff on and as I adjusted it, she was so engrossed in other things she didn't notice. Her colleague arrived, sat on the windowsill, chatted about her new car and the patient didn't seem to exist to them. The nurse wrote the vitals on her surgical glove, walked away talking to her friend and took the glove off and threw it in the bin. And with all that followed that was the most unhappy hospital stay that that gentleman had ever had... So, it's not unusual.
- Maria, London
The reason for carrying on with the NHS, Teds, is because for the vast majority of patients it gets it right every time and all the time. With the millions of interactions that take place every day in the NHS they're are bound to be mistakes (and I am not saying that makes it right). Over 90% of people who use it say that had a good or better experience. Many people have their lives to thank for the NHS (members of my family included). Continue to knock it and we'll give the government the perfect opportunity they need to close it down. You'll also demoralise everyone who works in it. How about talking it up occasionally or doing what you can to help?
- Terry Ruth, Croydon, UK
I am sure the NHS Nu Labor manager will get another raise though!
- Jacqueline, Hampstead, London
I would never trust the NHS again, they have nearly killed me and one member of my family. They are the health provider of last resort for me and my relatives. Not that we can afford private care but trips to a family member in France are helpful!
- Bob, London
The NHS is an embarrassment and, unfortunately, what this poor family went through is now very common. From the experiences of myself, my family and friends, incompetence, carelessness and a lack of communication is rife. Many people I know have avoided going into hospital, even if it means refusing life saving treatment, or paying privately for procedures. If people feel like this, what’s the point of continuing with the NHS?
- Teds, London
