Hospital criticised by coroner

IPSWICH Hospital today said its most senior clinicians were making changes to the way they work in the wake of an inquest into a pensioner's death.


IPSWICH Hospital today said its most senior clinicians were making changes to the way they work in the wake of an inquest into a pensioner's death.

Greater Suffolk coroner Peter Dean criticised the hospital during 80-year-old Grace Bunn's inquest.

Dr Dean berated staff for poor record keeping and failing to respond to the concerns of Mrs Bunn's family.

He also considered referring a former hospital doctor to the General Medical Council for inappropriate language and failing to produce a report for the inquest.

As reported in yesterday's Evening Star, Mrs Bunn, of Packard Avenue, Ipswich, was admitted to the hospital in August 2004 after a heart attack and was fitted with a temporary pacemaker on August 8.

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The family told the inquest that Mrs Bunn began to show signs of confusion and redness around the site of the temporary pacing wire - possible signs of infection.

After blood test results showed that MRSA was present on August 13, the wire - itself found to be contaminated with MRSA the following day - was removed.

Mrs Bunn died on August 14 and a post mortem found that Mrs Bunn had aspirated, drawing stomach content into the lungs, was suffering from heart disease and had septicaemia.

Dr Dean recorded a verdict of complications following necessary medical treatment, saying the temporary pacing wire was life-saving treatment for Mrs Bunn after she suffered crushing chest pain stemming from a coronary artery spasm.

But he said: “Complications could have been picked up earlier. The family were doing everything they could to make healthcare professionals aware.

“I can't be certain whether the outcome would or wouldn't have been different. The earlier an infection is realised, the better your chances of recovery.

“If there was an immediate response to the family's concerns, even if the outcome had been the same, then the family would have felt that everything that could have been done, had.”

Hospital spokeswoman Jan Rowsell said: “We take very seriously indeed the issues raised by the coroner. A team of the most senior clinicians are already addressing many of the issues, which date back to August 2004.”

DR Dean said that he had been left to “piece together” what happened to Mrs Bunn in the days before her death, because of the hospital's poor record-keeping.

It emerged at the inquest that Dr Reshma Patel made no notes about her meeting with Mrs Bunn's family on August 11, at which - according to the family - they talked about Mrs Bunn's redness and confusion.

There are also no notes to show which mystery doctor ordered blood cultures to be taken on August 11 - the sample that revealed the MRSA.

Dr Dean said: “As with so much of what took place here, the duty of actually recording what doctors or nursing staff did does not fully cover what took place. In some places, they don't cover what took place at all. That's not to detract from some of the medical care given.

“There was also failure to respond fully to concerns raised by the family. When they did finally make contact with medical staff, I find it extraordinary that Dr Patel did not find it necessary to record that meeting or instruct any medical response. There is no indication in the notes that she actually went to see Mrs Bunn.”

Dr Dean also said that a swab of the wound area, that may have revealed the presence of MRSA, was not taken.

Consultant microbiologist at Ipswich Hospital, Dr Richard Kent, told the inquest that if Mrs Bunn's dressing had already loosened, he would have recommended swabbing.

In addition, Dr Liam Ring - who used to work at the hospital and was involved in Grace Bunn's care - was narrowly spared being referred to the General Medical Council.

Dr Dean said his “lesson had been learned”, but said the inquest had “heard from the family about language used which may be considered inappropriate” and added that the inquest “would have been considerably easier had we had a report, and a report at an early stage.”

Dr Ring, who said he had not looked at his e-mails, apologised.

Have you experienced problems with Ipswich Hospital's record keeping or family communication? Write to Your Letters, Evening Star, 30 Lower Brook Street, Ipswich, IP4 1AN or send us an e-mail to