Inquest hears of faulty machine

A HOSPITAL'S blood testing machine failed to tell doctors of a patient's dangerously thin blood, because its warning system had been switched off, an inquest heard.

The coagulometer, designed to test how well a patient's blood clots, was used at West Suffolk Hospital, in Bury St Edmunds to test the blood of artist Lawrence Self, 77, who taught at the art school in Ipswich.

Doctors thought Mr Self, of Lower Road, Rattlesden, either had a problem with his blood or had meningitis.

Tests on his blood were ordered when he was admitted to the hospital on Christmas Day last year, but they came back showing there was no problem.

It was not until the following day when medical staff ordered the tests to be carried out again that the truth was discovered – that his blood was dangerously thin.

He was immediately sent for an emergency CT scan which discovered a massive brain haemorrhage.

On December 28, Mr Self, who held several exhibitions of his landscape, still life and portrait pictures, died.

At an inquest yesterday , in Bury St Edmunds, Ashe Self, his wife, said: "They did a clotting test and when the result came back I was astonished – it didn't seem reasonable.

"I was surprised it wasn't questioned because the high-tech machines were blinding us to what was going on."

An investigation subsequently revealed that the reading had been false, but it had not been caught as the computers 'warning flags' had been turned off.

Dr Iain Singer, consultant haematologist at the hospital, told the inquest that it was not "standard" to switch off the warning flags and steps had now been taken to ensure it could not happen again.

The previous system involved running the blood sample through two coagulometers to get a result. However, now the system has been changed to involve a manual test, should the machines not produce a reading.

Greater Suffolk coroner Dr Peter Dean asked if it would have ultimately made any difference to Mr Self, but Dr Singer added: "It is not certain the incorrect result affected the outcome."

The inquest heard how nobody knew how the machine came to be altered as the manufacturers said it was not done by them and Dr Singer said no one in the laboratory at the hospital had the expertise to do it.

Andrea Molyneaux, of the Department of Health's Medical Devices Agency, called in to examine the case, explained that the warning flags can only be switched on or off by someone going into the computer's software.

She also told the inquest how a further safety check was that a quality control sample should be put through the machine three times a day, yet on Christmas Day this was only done once in the morning.

Yvonne Field, the hospital's head biomedical scientist, admitted: "We cannot say how long the programme had not had the flags on. We think there was possibly a small bubble or blip which the instrument detected. We had not had any previous reports of this problem."

Dr Dean said of the false reading: "The apparently normal clotting time took the diagnosis more towards meningitis than a problem with blood clotting."

He added: "The circumstances are quite unique and a lot of lessons have been learnt and things put in place to prevent other tragedies occurring."

Dr Dean recorded a narrative verdict which read: "Mr Self died from a cerebral haemorrhage following over anti-coagulation with Warfarin. This increased level of anti-coagulation was not recognised initially due to incorrect settings on the relevant machine."

Speaking after the hearing, Mrs Self said: "Our distress is immense but we hope that things can be learned to stop this happening again.

"There clearly are lessons to be learned. No one can be certain that he would not have survived if the mistake had been discovered earlier."