Bristol, UK – 20th March, 2020: A grieving husband feels let down by Southmead Hospital after staff failed to administer a drug that could have saved his wife’s life on time. The health board has said it accepted the findings from the coroner - who said the woman’s death was contributed by neglect - and said it was determined to learn from the case.
Lesley Julie Brass, 58, was admitted to hospital on October 2018 after falling at home and cutting her head.
The disabled woman from Portishead - who was admitted to the plastic surgery ward - was found to have raised potassium in her blood, which is classed as a medical emergency because of the risk of triggering heart problems.
Her inquest heard severe hyperkalaemia should be treated within 15 to 30 minutes of the blood results being available.
In the case of Mrs Brass, who died on October 22, 2018, the drug was only administered after she had a cardiac arrest nearly an hour after the results came in.
Gary Brass said: “It has been awful - Lesley was my wife and my best friend. We were extremely close and I now feel this terrible void inside me. It is so hard to wake up every morning and that she is not there. I still say goodnight to her every night. It is horrible - her death was unnecessary and I am disappointed with the hospital. I have always been a fan of the NHS, but I now find it hard to have the same amount of trust. She is such a big loss and I still cannot believe that she is gone.”
The 60-year-old said his wife was disabled and suffered from diabetes and neuropathy, which affects the body’s extremities.
Mr Brass - who was married to Mrs Brass for 38 years - criticised the hospital for a lack of transparency over the matter.
The dad-of-two said it took nearly 13 months for him to find out about the concerns around her death, reading hospital statements that had been sent to the coroner.
Charlotte Tracy, of Barcan + Kirby’s medical negligence team, said the inquest concluded on March 2.
A narrative conclusion was recorded in the inquest, which said: “Mrs Brass was an inpatient on the Plastic Surgery ward at Southmead Hospital when she developed severe hyperkalaemia, a condition requiring emergency treatment.
“The hospital’s own internal procedures required that severe hyperkalaemia must be treated within 30 minutes, and the relevant staff looking after her were aware that she faced a life threatening emergency, but the window for effective treatment expired without the required treatment being given, and as a result Mrs Brass went into cardiac arrest and sadly died.
“Her death was contributed to by neglect.”
The solicitor said the blood test results came in just before 12.30pm - meaning the medication should have been administered by 1pm.
Instead, Mrs Brass was taken for an ultrasound at 1.05pm and had the cardiac arrest at 1.22pm, at which point she was given the drug.
Ms Tracy added: “Mr Brass has been looking for answers since October 2018, whilst also dealing with the huge loss of his beloved wife, Lesley.
“We hope improvements can be made to ensure life-saving treatment is given, and protocols met, at Southmead Hospital in order to prevent further avoidable deaths, and that families are treated with honesty and respect during any investigation process.”
What the health board says
Dr Chris Burton, North Bristol NHS trust medical director, said: “We accept the coroner’s findings and are extremely sorry that Mrs Brass’ care fell below our normal high standards.
“We didn’t act quickly enough to treat her deteriorating condition, which was unacceptable. We are determined to learn from this and have since tightened our processes for escalating unwell patients and have given additional training to the relevant staff.”
Source: https://www.bristolpost.co.uk/news/bristol-news/grieving-husband-let-down-southmead-3966589