A CATALOGUE of failures by staff at Blackburn Royal Infirmary and White Ash Brook Nursing Home, Oswaldtwistle, led to the death of an 82-year-old grandmother.
An inquest heard Eveline Birtwell, of Elmfield Street, Church, died at the hospital in August 2001. She was admitted from the nursing home after being given an overdose of prescription drugs.
Recording a verdict of accidental death, Coroner Michael Singleton said an overdose of Diltiazem - a beta-blocker that relaxes heart muscles and lowers pulse rates - had ultimately contributed to Mrs Birt-well's "untimely death".
The inquest - held at Clitheroe Town Hall - heard how Mrs Birtwell, who suffered from dementia, was taken to Blackburn Royal Infirmary after collapsing.
Doctors decided to remove Diltiazem from her medication and to increase the dosage of Sotalol, but the change was not written onto her notes. Within 24 hours, she was moved to an intermediate bed at White Ash Brook.
In a written statement, Deborah Jackson, a nurse at the home, admitted adding Diltiazem and Tildiem Retard onto her medication record - something that should only be done by a doctor.
Examples of both, which the inquest heard were the generic name and brand name for the same drug, had been found in Mrs Birtwell's property bag.
Staff at the home discovered they did not have any Tildiem Retard, so a phone call was made to Brierfield Pharmacy which delivered the drug but failed to pick up a prescription authorising it.
Dr Arthur Manuel, part-owner of the nursing home, told the inquest he had come across the entries for Diltiazem and Tildiem Retard on Mrs Birtwell's records a couple of days later and signed them.
In his summing-up, Mr Singleton said: "It is right to say that there are a number of failures that have been clearly identified."
Among the criticisms he made were:
- Doctors at the hospital's medical assessment unit should have written the change in medication on to Mrs Birtwell's records and the medication she brought into the hospital should not have been put into the property bag she took to the nursing home.
- Mrs Birtwell, as a dementia patient, should not have been considered appropriate for intermediate care.
- Deborah Jackson should not have added medication to the medical chart and Dr Manuel should not have put his signature to entries without checking the medical records.
- The pharmacy should not have delivered the drug without a prescription and someone should have noticed that Diltiazem and Tildiem Retard were the same drug.
Mr Singleton said several opportunities to rectify a number of mistakes had been lost. But he did not accept it would have been so obvious to any of those involved that a gross error had been made, such that failing to act on it would be neglect.
Speaking after the inquest, Mrs Birtwell's daughter Anita Raven slammed the Crown Pros-ecution Service's earlier decision not to prosecute anyone for her mother's death.
She added: "I am disappointed the CPS did not take it up. I feel let down after all this time. It has been two years and three months now and it's been a nightmare. Hopefully I will be able to move on now."