A hospital blunder killed a 93-year-old war veteran after he was given the wrong drug – and staff didn’t realise he’d collapsed for an HOUR, an inquest heard.
Former Royal Marine Robert Welch was given insulin instead of Dextrose during a fatal mix-up at a hospital in Grimsby, North East Lincs., in June of last year.
Robert, who fought in the Burma campaign during the Second World War, was being treated for a Urinary Tract Infection (UTI) when junior nurses dropped the clanger.
He became hypoglycemic and went into cardiac arrest – but it took staff at Diana, Princess Of Wales Hospital up to an hour before they found him slumped in his bedside chair.
His son Andrew Welsh, 63, of Newcastle, Tyne and Wear, said: “This was just an absolute tragedy and as part of my dad’s legacy this can not happen again.
“I don’t want to slam the two nurses involved and the coroner commented on my reasonable approach to the incident.”
Andrew’s wife Chris Welsh added: “What happened is something that should not happen in hospitals, it doesn’t matter the age of the patient – that could have been a 30 or 40 year old.”
The inquest at Cleethorpes Town Hall, North East Lincs., heard post mortem examination results which revealed Robert died as a result of cardiac arrest, caused by an insulin overdose.
He was resuscitated after three attempts with a defibrillator used by the emergency “crash team” at the hospital on June 30.
But the most senior doctor, Dr Christopher Gooch had to tell Mr Welch’s son Andrew Welch that the prognosis for his father was that he could not survive.
Robert had been in hospital for five days when he medicine mix-up occurred, but had been treated for his UTI, Andrew said.
Grimsby and North Lincolnshire coroner Paul Kelly, who gave a narrative conclusion, said Mr Welch had been administered medication “other than that which had been prescribed”.
He told the court: “I am noting the difference in the accounts from nursing staff.
“Inadequate supervision of relatively junior nursing staff together with inadequate training in the preparation of medication contributed to the mistake.”
But the coroner said he would not make any findings to prevent any similar deaths because the hospital Trust which runs the hospital had put measures in place to introduce new guidelines.
Giving his condolences to Mr Welch’s family, Mr Kelly said: “It would have been quite easy for you to be super critical, but that is not a route you have taken and you have shown courtesy and restraint.”
Andrew, who is Medical Director of Newcastle Hospitals, responsible for the treatment of patients who use the 2,000 beds in Freeman Hospital and The Royal Victoria Hospital.
He said his father was fit and healthy up until six months before his death and would enjoy walks and rode horses well into his 80s.
Robert was a coxswain for landing troops in the Royal Marines during the Egyptian and Far East conflicts and later became a civil servant after leaving the forces.
Following the hearing, Andrew said: “I was quite confident they (hospital trust) had grasped the nettle – they have reacted quickly and I am comfortable with what they have done.
“My dad had a good life and was on the decline, obviously if this would have happened to someone younger then it would have been an abysmal.
“My main aim was to make sure it does not happen again and they have taken it seriously and have reacted positively.”
Consultant Surgeon Andrew, who said he had taken the high ground, added: “It is a really tough time in the NHS because of all the pressures they face and they are doing their best.
“The trust has been criticised in the past but I do not believe that my father’s experience should undermine public confidence as effective action appears to have been taken.”
Susan Peckitt, deputy chief nurse at Northern Lincolnshire and Goole NHS Foundation Trust, which runs Diana, Princess Of Wales Hospital, said: “We would like to offer Mr Welch’s family our sincere condolences for their sad loss.
“We have now put a number of measures in place to reduce the chance of a medication error such as this happening again.”
These measures include new guidelines of hyperkalaemia in adults, annual training on providing IV medications and fluids and a review of staff skills-mix on the ward involved and additional training to the staff involved.
