Coroner criticises hospital blunders

Christopher Farrington . . . missed opportunities

THE Pennine Acute Trust has been criticised for a series of blunders, following the death of an Oldham man.

Christopher Farrington (46), was admitted to A&E at the Royal Oldham Hospital on September 5, 2010 feeling unwell. He had suffered chronic renal failure, which later resulted in his death, a Rochdale inquest heard.

Coroner Simon Nelson said there had been “missed opportunities” when information from a pathology lab wasn’t acted on.

A wireless system linking patients to the coronary care unit was found to have become disconnected. Staff only realised the failure when Mr Farrington was found collapsed after a heart attack.

Abnormal blood results — sent over when hospital equipment failed — were received by an unknown staff member who didn’t alert anyone or give treatment. The results showed a raised blood potassium level — which can cause heart problems in dialysis patients.

Senior doctor Dr Michelle Regan said if she had been aware of the results she would have given Mr Farrington extra calcium.

“There was a responsibility upon myself to check those results,” she said. “I was the senior clinician looking after him. There are lots of different reasons why that might not have happened, but I can’t say for a fact.”

Another clinician also downgraded Mr Farrington’s treatment.

Mr Farrington’s mother, Elizabeth Stewart, said her son was an organ donor but staff took no action in this regard following his death

Michael Griffiths, then the hospital’s divisional nurse manager, started a detailed investigation and said he was confident policies implemented since Mr Farrington’s death would prevent similar incidents.

Mr David Lewis, solicitor for the trust, said there was no expert evidence to suggest how well Mr Farrington would have responded to treatment.

Pathologists said death was from kidney failure caused by reduced blood supply to the heart and other conditions.

The coroner gave a “narrative” verdict. He said: “His death may have been averted had there not been a failure to act on the results. I have not included the word neglect, as in coronary terms it has to be gross neglect. I don’t believe the failure was gross, but changes that have come about following the death of Mr Farrington will be scrutinised by me very carefully.”

Speaking after the inquest, Mrs Stewart said she was disappointed with the result and asked why the trust had made the policies if they felt they had not neglected her son.

“I’m glad the polices have been made but they won’t bring Chris back,” she added.