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FATAL HOSPITAL ERROR MISSED FOR SIX DAYS.

Byline: Warren Manger HEALTH REPORTER

A 52-year-old patient died in a Coventry hospital after doctors failed to give him essential blood thinning drugs following brain surgery.

Edward McKean, a fatherof-three, needed the medication to prevent life-threatening blood clots after an "aggressive" operation.

However, they were accidentally missed off his drug chart at University Hospital, Walsgrave, an inquest heard.

As a result a blood clot in his left leg broke free and blocked his artery causing a fatal pulmonary embolism.

An inquest ruled that doctors and nurses missed numerous opportunities over six days to spot their mistake and that "neglect" had contributed to the 52 yearold's death.

Mr McKean's partner Susan Rickards said: "The hospital rang me at five in the morning and told me there was an emergency, so I shot up there.

"I assumed Eddie had fallen over so I sat in the car and put mascara on. I thought if he saw I was calm it would help him to keep calm.

"I thought he might have broken his arm or leg, but when I got to the ward they told me he was gone."

Contracts manager Mr McKean, who loved walking in the Lake District with his family, was diagnosed with a rare tumour in his nasal cavity and skull in 2011.

Chemotherapy shrank the tumour, but doctors feared he could develop a brain infection unless they repaired the damage it left behind.

Mr McKean had the major operation at University Hospital on April 3 last year. He was initially given drugs to reduce the "high risk" of blood clots. However, when a junior doctor copied up Mr McKean's drug chart several days later she accidentally missed off the anti-coagulants.

Consultant neurosurgeon Hussien El-Maghraby said that kind of human error did happen.

"What is serious was that it was not picked up for six days," he said.

On April 22 last year, Mr McKean suffered a fatal pulmonary embolism as he walked to the toilet.

A post mortem found he had already suffered a smaller embolism which could have alerted doctors to their mistake and saved his life.

Mr El-Maghraby admitted he was so frustrated when he learned what happened that he sent an email to the chief executive's office.

Deputy coroner Louise Hunt asked him: "On a scale of one to ten, how serious would you say these collective failings were?" Mr El-Mugrahby replied: "Very serious - ten out of ten. That's what made me send an email."

He admitted Mr McKean probably would not have died when he did if he had been given the drugs.

The inquest at Coventry Magistrates Court heard the hospital had since improved ward rounds and made other changes to minimise the risk of a similar tragedy.

Dr Mike Iredale, deputy medical director, apologised to the family for the "unimaginable distress and grief" the hospital had caused them.

He accepted serious mistakes were made and promised the hospital would continue to improve its procedures.

However, Ms Hunt said she was concerned some of those steps still had not been taken.

She asked the hospital to send her written confirmation that those measures were in place within two months.

Mr McKean, who lived in Solihull, had three adult sons and a step-daughter.

Several members of his family wept as the verdict was read out.

After the hearing Ms Rickards said: "I have fought for this inquest for ten months to stop this being swept under the carpet.

"I wanted to make sure the hospital answered for its mistakes."

CAPTION(S):

DIED: Edward McKean

ACCUSED: University Hospital in Coventry
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Publication:Coventry Evening Telegraph (England)
Date:Apr 2, 2013
Words:596
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