A 'sprightly' Birmingham mother died after failings in her care at Good Hope Hospital while resident doctors were on strike, an inquest has heard. Much-loved Geraldine Miles, a mum-of-five known to most as 'Dina', had been living independently, cooking, shopping and driving before she admitted herself to hospital with diarrhoea on November 7.
Hospital Discharge and Missed Treatment
After investigations, the 84-year-old was deemed medically fit and sent home on November 17. However, under-pressure medics had failed to act on the 'very basic' problem sitting on her record for four days. The untreated potassium levels identified in her test results led to a cardiac arrest only hours after her release. After being readmitted to the Sutton Coldfield hospital, it was found she had suffered a catastrophic brain injury and she died on November 26.
Coroner's Findings
Area Coroner Emma Brown concluded the failures would not have happened under normal working conditions. She said: "I'm only putting aside neglect [by UHB] because the industrial action clouded and complicated things." Both 'system and individual failings' were identified in Mrs Miles' case and "her death was avoidable and due to omissions in medical care," she added, recording a narrative conclusion. "It really shocks me that the result can sit there for four days," said the coroner. "I do think the industrial action had a bearing on this case." Her cause of death was ruled as hypoxic brain injury due to a cardiac arrest, due to hypokalaemia (low potassium) as a result of clostridioides difficile.
Sequence of Events
At the start of Mrs Miles' admission, she was investigated for an internal bleed, however "no source of bleeding was found," the court heard. While in hospital, she developed signs of a chest infection and suffered two falls - although she didn't appear to have any injuries from those. Crucially, she underwent tests at the hospital, one of which returned on Friday, November 14 and revealed a low potassium level of 2.9. "That was not a critically dangerous level which would have resulted in a direct call from the lab, but action was required," said the coroner. "As a result an alert was put on the system which would have come up whenever her records were entered. It has emerged that the alert was dismissed by a number of people who could've acted upon it, until November 15 when Dr Mark Andrew [a consultant] accepted it, which should have meant that he has seen it and had in place a treatment plan."
Consultant's Actions
Dr Andrew said he verbally instructed a locum resident doctor to put a plan in place to prescribe a potassium supplement, however this was not done. The consultant failed to add a written note to the system to inform other medics. "That resident doctor is not able to be spoken to. Dr Andrew accepts he did not make a record of his plan in the patient's notes," Mrs Brown added. Mrs Miles was deemed medically fit by Saturday, Nov 15 and she was then awaiting a care package for her discharge. After a remote handover on 'Teams' on Sunday, Nov 16 her care was passed onto consultant Dr Sukhdev Singh from Monday, November 17 - the day of her discharge. However, it was claimed Dr Andrew did not include the potassium levels in his handover. "It continued to go untreated and a new consultant took over responsibility for her care - his position was he was not informed by Dr Andrew about her low potassium levels," said the coroner.
Apology and Impact of Strikes
Dr Singh told the court: "We would have been horrified to see that she hasn't had anything prescribed. I wish that information had been imparted to me because we could have spotted that and started supplements." He apologised to the family, adding his belief that the test result would not have been missed if they had their usual resident doctors. Due to the strikes, the ward was operating with two locum doctors who were "unfamiliar with gastroenterology" - instead of up to four junior resident doctors. "It wouldn't have been missed, it would have been spotted on the Friday, it would have been spotted and treated and if by some fluke, it hadn't, it would have been spotted on the Monday morning," Dr Singh added. The consultant added: "If the resident doctor had presented the history the other way around and said 'this is a lady with low potassium noted on Friday and hadn't had any supplements prescribed', I would not have discharged her. But as the consultant responsible, I have to say I made a mistake there. I want to apologise to Mrs Miles' family for the mistake that I made." He went on: "This has really shaken us up. We have discussed this as a team and we have shared our experience with Good Hope Hospital. I know my colleague is disseminating our experience with the Trust."
Coroner's Conclusion
Mrs Brown concluded: "Dr Singh was very clear this was likely a result of the industrial action and increased pressures." Although a University Hospitals Birmingham investigation did not find the strike was a 'significant factor', the coroner said: "This is a mistake that went on for four days. In normal times, this would be considered a gross failure." Ensuring potassium levels were correct was "very basic medicine," she added. "They were having to act in a different way and carrying out adjustments in their usual roles. As soon as they are shifted out of their normal roles, their cognitive load increases and the risk of them missing something increases. I accept Dr Singh's evidence that this would not have happened under normal working conditions, for four days for these results and the actions necessary to be missed." She did not issue a prevention of future deaths report, as she felt steps subsequently taken by the trust will "reduce the risk of these factors arising again" - should another strike take place. BirminghamLive has contacted University Hospitals Birmingham for a comment.
