A retired gardener suffering from dementia died from internal bleeding following a fall because the hospital did not notice his blood was failing to clot properly.
David Simpson, who was 73 when he died, fell off a chair at Hollymount Nursing and Residential Home in Blackburn in August, Lancashire and was taken to Royal Blackburn Hospital where staff failed to realise the drugs combination prescribed by his GP made it impossible for his body to make his blood clot correctly.
An inquest taking place to investigate Mr Simpson’s death revealed the hospital missed many chances to rectify the problem, and only took a blood sample from the 73 year old when it was too late. It also found medical staff tried to take a sample on previous occasions but ignored the situation rather than trying again when they failed to collect enough blood. A subsequent international normalisation ration (INR) check showed Mr Simpson’s level at 12 instead of the normal 2.6.
He was then given treatment by the hospital but died three days later. The coroner in charge of the hearing, Michael Singleton, said: “He simply bled to death internally.”
Mr Singleton also told the court: “The relatively minor fall would have itself not have caused any significant injury had it not been for the fact blood-clotting agents were such that – once there was a minor bleeding from a minor blood vessel – it simply did not stop.
“There was an opportunity to deal with that at the Royal Blackburn Hospital because on admission they took a blood sample to do the full blood count, but there was insufficient taken to collect the INR.”
He also said he believed the initial problem started with Mr Simpson’s doctor who initially prescribed the unsuitable mixture of drugs, adding it was a “personal failing” on the part of the GP. In addition, he described the care Mr Simpson received at the hands of both his doctor and the hospital as a “systematic failing” and said he will write to hospital bosses to ensure the same thing does not happen to any other patients.
Mr Simpson had been at the care home for only a short time following previous brief stays for respite care. At the time of his accident, which was described as relatively minor by his wife Pat and a care home assistant, Mr Simpson had no visible injuries but was taken to hospital after complaining of pain in his left groin and when he was unable to bear weight. Pat also added she had told hospital staff her husband was spitting up blood but was told by them he should clean his teeth properly.
East Lancashire NHS Trust, of which the Royal Blackburn Hospital belongs, is currently conducting an investigation into the circumstances surrounding Mr Simpson’s death. It has offered its condolences to his family.
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