The tragic death of a popular and vibrant Otley grandmother could have been avoided if proper hospital procedures had been followed.
An inquest has taken place into the death of 75-year-old Gwendolen Bingham, who died after a revision knee replacement at Harrogate District Hospital on November 3, 2012.
The four-day inquest at Harrogate Magistrates’ Court heard that Mrs Bingham was in good health, lived independently and the operation was straightforward with no complications expected.
However, her condition deteriorated over the weekend of October 20 and 21, 2012, when signs of renal failure were not picked up and she subsequently suffered a heart attack and stroke that led to her death.
Evidence given by consultant pathologist Dr Lowe, supported by the trust clinicians, was that failures in treatment during the weekend of 20th and 21st on the balance of probabilities caused or materially contributed to Mrs Bingham’s death.
During the inquest Coroner Mr Geoff Fell, considered the quality of care provided to Mrs Bingham and a number of issues were identified including ineffective and inconsistent handover, delay in communication of abnormal blood results, incomplete and inconsistent documentation and incomplete medical care at the weekend.
Evidence was heard from the nurses who expressed deep concern at the staffing levels and quality of nursing staff at that time exacerbated by reconfiguration of wards, sickness and training.
Mrs Bingham’s death led to a review of staffing, procedures and policies and revised practice that has been introduced at Harrogate District Hospital to minimise the likelihood of such events happening again.
Mrs Bingham’s daughter, Nicki Harrington, said: “I believe this was an avoidable, tragic event that should not have happened. We should have complete faith and confidence in our hospitals and the medical profession when anyone goes in for anything including elective surgery.
“As a family we believe that we are clearer about what happened to Mum that weekend and hope that no other family has to go through the traumatic experience we have. Mum was such a lively, outgoing person and had the knee operation so that she could continue to lead an independent, active and full life, playing bowls and enjoying theatre trips with her partner, Brian, being with her children and eight grandchildren as often as she could.
“Sadly, her life has been cut short. We are devastated and feel deprived of someone we loved dearly.”
Speaking after the inquest, Dr David Scullion, medical director at Harrogate and District NHS Foundation Trust, said: “We would like to express our deepest condolences and sincere apologies to the family of Mrs Bingham for the failings in the care provided to her.
“We accept the findings of the Coroner and acknowledge his conclusion. We have thoroughly investigated Mrs Bingham’s death and this has led to a detailed action plan being implemented. We have already introduced a number of improvements. These include:
- more robust handover arrangements between clinicians;
- changes to the automatic alert system for the communication of abnormal blood test results;
- adopting the new National Early Warning Score system, a more sensitive system than we had before to identify and alert to a deterioration in a patient’s condition; and
- increasing the number of staff working on Wensleydale ward, including at weekends.