A dad-of-three died on the bathroom floor of a hospital after a bungling junior doctor left life-saving drugs off his medication chart, an inquest has heard.
Medics failed to realise Edward McKean, 52, was not receiving vital blood-thinners for SIX DAYS after he underwent brain surgery to remove a benign tumour.
But he did not receive the drugs – designed to reduce the risk of blood clots – after a junior doctor missed them off his treatment chart when she copied it up.
As a result, a clot in Mr McKean’s leg broke free and blocked an artery, causing a fatal pulmonary embolism as he walked to the toilet.
A coroner ruled that doctors and nurses missed numerous opportunities to spot their mistake and said “neglect” had been a contributing factor to his death.
An inquest at Coventry Magistrates Court on Friday heard that the keen walker’s life could probably have been saved if the mistake had been picked up.
Mr McKean had surgery to correct a rare tumour in his nasal cavity and skull at University Hospital Coventry on April 3 last year.
He initially received the anti-coagulant medication after the op but stopped receiving it following the error by the junior.
The contracts manager, from Solihull, West Mids., collapsed and died as he walked to the toilet on April 22 last year, almost three weeks after his operation.
Mr McKean’s partner Susan Rickards told the inquest she “fought for a year” to stop the tragedy being “swept under the carpet”.
Describing the moment she learned of his death, she told the inquest: “The hospital rang me at five in the morning and told me there was an emergency, so I shot up there.
“I assumed Eddie had fallen over so I sat in the car and put mascara on.
“I thought if he saw I was calm it would help him to keep calm.
“I thought he might have broken his arm or leg, but when I got to the ward they told me he was gone.”
Consultant neurosurgeon Hussien El-Maghraby admitted the mistake should have been detected sooner.
He said: “What is serious was that it was not picked up for six days.”
Mr El-Maghraby added that when he learned what had happened he sent an e-mail to the hospital’s chief executive.
Deputy coroner Louise Hunt asked him: “On a scale of one to 10, how serious would you say these collective failings were?”
He replied: “Very serious, 10 out of 10. “That’s what made me send an e-mail.”
The inquest heard the hospital had since improved ward rounds and made other changes to minimise the risk of a similar tragedy.
Ruling that neglect had contributed to Mr McKean’s death, Ms Hunt asked the hospital to send her written confirmation that it had implemented measures to prevent similar mistakes occurring again.
Dr Mike Iredale, deputy medical director, apologised to the family for the “unimaginable distress and grief” the hospital had caused them.
He accepted serious mistakes were made and promised the hospital would continue to improve its procedures.