Woman died after hospital sent crucial information to pensioner’s obsolete email address
Blood clot patient did not get appointment details or life-saving medication
08 June, 2017 — By William McLennan
A HOSPITAL apologised after a pensioner died when nurses failed to deliver life-saving medicine to her home because staff sent an appointment request to an “obsolete email address”.
Doreen Stapleton, 78, was discharged from the Whittington Hospital after suffering a blood clot in her lungs and was told that a nurse would visit her at home every day to deliver a blood-thinning injection. Ten days later, having never received the anti-coagulants, she suffered a fatal blood clot.
Coroner Mary Hassell said daily injections of the drug, called tinzaparin, did not take place “because an obsolete email address had not been deleted by the hospital and so was used for the referral to the district nursing team, who then never received it”. At an inquest in February, she concluded: “If she had received the tinzaparin as prescribed for the preceding 10 days, Doreen would not have died when she did.”
Ms Hassell said she had been reassured that the hospital had taken steps to make sure an obsolete email address would not again lead to such a tragedy. However, she said that Ms Stapleton, from Archway, had not been adequately informed of the deadly consequences if she did not receive the injections, and therefore did not chase it up when nurses failed to arrive for the daily visits.
Ms Hassell sent a legal warning to hospital chief Simon Pleydell calling for changes to be made to prevent further deaths. She wrote: “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (ie, death) of the visits and medication administration not taking place.”
A spokeswoman for the hospital said: “We would like to offer our deepest condolences to the family of Mrs Doreen Stapleton. We recognise that we didn’t provide Mrs Stapleton with the follow-up care she needed and we are extremely sorry for this. Following Mrs Stapleton’s tragic death, we conducted a full investigation into the circumstances surrounding her missed nursing referral. We have already taken significant steps to ensure that we learn from the important lessons identified from Mrs Stapleton’s death, and all defunct email addresses have now been removed from our system.”