Retired teacher dies after basic blunders by FOUR doctors

Despite her age, 85-year-old Gertrude Danforth's treatment in Barnsley District Hospital should have been routine.

But at least four doctors were responsible for "gross failure to provide basic medical attention" and she died in hospital a month later.

Failures to carry out simple procedures and tests and bad decisions on treatment culminated in the pensioner suffering a fatal stroke.

Coroner Naomi Cuthbert returned a verdict of "natural causes contributed to by neglect" following a lengthy inquest in Sheffield and said she would have survived had proper treatment been given.

She said there was "categoric and overwhelming" evidence of a "causal connection" between her initial hospital care and her death.

In a damning indictment of both junior and senior medical staff, the coroner identified four separate incidents of "gross failure" in Miss Danforth's care.

The "independent and alert" pensioner was originally admitted on 15 July 2005 after being hit by a car near her home in Stairfoot, Barnsley, and suffering a broken right knee.

She later suffered dehydration and a serious drop in blood pressure, but there was a three-and-a-half hour delay in nursing staff finding a junior doctor. Even when the doctor was found he seriously blundered in his treatment, the inquest heard.

The coroner said he failed to give her the fluids she needed and appeared not to recognise the pensioner was suffering from acute renal failure.

The junior doctor, who has returned to India and could not be traced to give evidence, prescribed an 'inappropriate and possibly harmful' drug which risked causing further kidney damage.

However, she was deemed well enough to be discharged to a respite care home on August 5.

Two days later she was taken back to the hospital's casualty unit suffering from vomiting and high temperature.

An expert told the inquest she should have been given a chest X-ray, scan and urine analysis and admitted for further care.

But a locum doctor failed to carry out proper tests and sent her home without realising she had a dangerously low blood sodium level.

The coroner concluded that had she been treated properly at this stage her "subsequent demise may have been prevented."

Even when she was readmitted on 8 August - the next day - the mistakes in her care continued.

Tests showed Miss Danforth's blood sodium level was so low it could have caused a coma or seizure at any time. But after the results came back there was a delay of at least four-and-a-half before a doctor saw her.

The inquest heard the doctor should have ordered tests to find the cause of the blood problem and consulted a senior colleague.

"Such tests are rapid, routine, standard and easily available in all hospitals," said the coroner. "These tests were not requested."

These mistakes meant the loss of a vital 16-hour window of treatment. Yet the situation went from bad to worse when a senior doctor was called in, the inquest heard.

An acute medicine consultant came up with an "obscure" diagnosis for her problem which, according to expert evidence, was "exceptionally unlikely" to be correct.

The coroner said the right questions were not all asked and her treatment at this stage also amounted to "gross failure".

A few hours later Miss Danforth suddenly deteriorated, became unconscious and had apparently suffered a stroke. She died at the hospital on 15 August.

In her conclusions, Miss Cuthbert blamed the patient's needless renal failure on her hospital care and said it probably caused her blood sodium problem, which in turn resulted in a stroke.

"I find that on the balance of probabilities, but for the failure to take action, Miss Danforth would have survived or her life would have been prolonged," she said.

The coroner is writing to the Barnsley District Hospital NHS Trust asking it to review the training of doctors at the hospital.

Miss Danforth taught at the same Barnsley school for 38 years and was a pioneer of nursery education in the town after the Second World War.

After the hearing Miss Danforth's sister Lillian Flatt, 83, said: "I am not surprised at the coroner's findings. I knew a lot of mistakes were made. It is the whole system at the hospital that was at fault."