Man died in St Mary’s Hospital after several staff errors, rules coroner

St Mary’s hospital must take action to prevent future deaths after a coroner ruled a man died in their care after several fatal errors. 

A report published on October 30 written by senior coroner Caroline Sumeray of the Isle of Wight revealed that Cuthbert Hingert, an Island man, died after a series of failings at the Newport hospital.

The 86-year-old man passed away on March 5 last year when he sustained a head injury after he was given incorrect medicines.

The coroner found at inquest that an on duty medical registrar did not check the medicines database to see that he had already been administered a stat (immediate) dose of antiplatelets and anticoagulant medication before prescribing a second dose of these medications.

Then the registrar prescribed a dose of aspirin that was four times the amount of a standard dose.

St Mary’s stock image

Mr Hingert had already been prescribed continuing doses of Fondaparinux and
Ticagrelor, which, in the coroner’s view were fortuitously not administered.

The inquest also revealed that one clinician treating Mr Hingert had not been trained to use the medicines database.

There was also a two hour delay in communicating a medication decision for the patient.

Mr Hingert then became confused but was prescribed a hypnotic drug, zopiclone which the coroner said “may not have been a sound clinical decision”.

The coroner’s final concern was that a nurse did not follow hospital protocol and make a DATIX incident report – which are there to help prevent future incidents of the same kind from happening again.

Suzanne Rostron, director of quality governance at Isle of Wight NHS Trust said: “I want to extend our sympathies to the relatives and friends of Mr Cuthbert Hingert.

“Cuthbert died on March 5, 2017 and we have fully reviewed his care leading up to that point.

“As a result the JAC computer system which records the medicines given to patients has been upgraded to ensure that all stat (immediate doses) will be visible to the prescriber on the front of the chart for a 24 hour period which will reduce the occurrence of a repeat stat dose.

“The details of this case have been used to underline the need for this change and in the training of staff (doctors and nurses) who prescribe medication.”

The trust has written to the coroner and provided an action plan in response to the Regulation 28 direction but we think it would be for the coroner to decide whether to publish that letter and accompanying plan.