Neglect and “gross failures” of care at a Harrow hospital contributed to the death of a 64-year-old man from Mill Hill, an inquest heard today.
Rajnikant Harmanbhai Patel, from Sefton Avenue, died from renal failure on May 15, 2008, following a series of miscommunications among staff at Clementine Churchill Hospital, in Sudbury Hill.
Despite being a diabetic with a long history of heart and kidney problems, Mr Patel’s symptoms went untreated after his admission to the hospital, at 5pm on May 12, because his regular doctor was abroad and his medical notes were unavailable.
A blood test ordered by the stand-in consultant, Dr Jayantha Arnold, was not carried out for four hours, and the results – which showed Mr Patel needed emergency treatment – were not communicated to the doctor or ward nurse.
Mr Patel had a cardiac arrest at 1.30am on May 13 and was transferred to Northwick Park Hospital, in Watford Road, where he died at 5.35pm on May 15.
Mr Patel’s nephew, Dilip Patel, from Watford, said he hoped the hospital would take “dramatic steps” to change its procedures in light of his uncle’s death.
“This inquest has helped me and the family to understand how the hospital made gross mistakes which led to my uncle’s death,” he said.
“A year ago we almost lost my father for similar reasons and we thought taking my uncle to a private hospital meant he would be given the best care possible, but, as we have heard from the experts, he received very poor treatment.
“My uncle should be enjoying the fruits of his hard work now. He was a very kind man and we will miss him a lot.
“We hope the hospital will take dramatic steps to change its systems to avoid this ever happening again.”
The level of potassium in Mr Patel’s blood was twice what it should have been, and his creatinine and urea levels were between five and seven times above normal, Hornsey Coroner’s Court heard yesterday.
These results constituted a “a serious cause for concern, requiring immediate treatment”, according to expert witness Dr Robert Flanagan, a forensic toxicologist.
Knowing their significance was “very basic medicine”, he added.
But the results were not passed on to Dr Arnold before Mr Patel’s cardiac arrest, despite having been communicated by the pathologist to staff nurse Nora Choudhuri three hours earlier, along with an instruction to repeat the blood tests.
Ms Choudhuri claimed she passed the results to resident medical officer (RMO) Tomasz Starega, but Dr Starega denied this. He said he was only told to repeat the tests because the first samples had been “spoiled”.
Orga Ycay, who was Mr Patel's designated nurse, also claimed Ms Choudhuri failed to tell her the test results, which were left unattended at the nurses' station.
Dr Starega said he did not ask what the results were because it was “not normal practice”, he was overloaded with patients and the results would shortly be available by hardcopy.
He decided to delay taking the blood until the early morning because Mr Patel had not been designated a “high risk” patient.
Coroner Fiona Wilcox, concluding, said: “When Mr Patel was admitted to the hospital his heart problems were known, but his renal failures were not. I find this incomprehensible given his long history of diabetes and the fact a blood test was taken on May 9, 2008.
“The senior nurse on duty said that outpatient notes are not routinely available at the hospital. I find this to be poor practice in a modern hospital when patient records are absolutely essential in order to provide good medical care.
“I find that the medical personnel should have known of the high potassium and I also find that the pathologist did pass on this potassium result.
“A failure to look at the full blood tests and to pass this information on to Dr Arnold, and the failure to request a simple ECG, are all gross failures in basic medical care and as such amount to neglect.”
The hospital has since revised its procedural guidelines on how to deal with blood samples showing high levels of potassium.
A spokesman said: “The death of Mr Patel is very sad and our most sincere thoughts and sympathies continue to be with his family and friends.
“The coroner’s verdict and her comments will be subject to the closest scrutiny and consideration, and will form a part of our continuing process of improving patient care.”
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