'Lessons need to be learned': Pensioner at Shrewsbury hospital given wrong medication before death
“Lessons need to be learned” according to an NHS report after a pensioner at Royal Shrewsbury Hospital was given the wrong medication before she died.
Retired shop manager Beryl Ashley, 83, was admitted to the hospital on October 11 last year with a gastrointestinal haemorrhage and died eight days later after her condition deteriorated.
She had been on anti-coagulant drugs, which act to prevent the blood from clotting, but a doctor recommended that particular medication be discontinued.
The inquest was told that the message was not relayed to staff and Ms Ashley, of Diksmuide Drive, Ellesmere, was given the drugs for a further two days before the mistake was spotted.
At an inquest held at Shirehall, Shropshire Coroner John Ellery said it was not possible to say whether the situation had contributed to Ms Ashley’s death.
After she died, a serious incident investigation was carried out by Shrewsbury and Telford Hospital NHS Trust (SaTH), which manages both Royal Shrewsbury Hospital and Princess Royal Hospital.
The investigation found that the message was given by a doctor but, due to workload pressures, the nurse responsible was pulled away on another task and did not deliver the update.
Delivering his conclusion Mr Ellery said the main issue was a “communication breakdown”. He said:
“SaTH has carried out a detailed investigation and they have identified the root cause and lessons that need to be learned going forward.
“The root cause was a communication breakdown. The instruction was given verbally but it was not carried out immediately.”
He recorded a conclusion of death by natural causes.
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