Warwick Hospital patient’s death down to ‘neglect’

David Game, aged 87, had an operation in Warwick Hospital for a hip replacement on June 30, 2009. But an inquest heard that after the operation nursing staff on Oken Ward failed to give him enough to drink or monitor his fluid levels. As a result he had kidney failure, this led to a chain reaction of multi-organ failure, and Mr Game, of Nursery Lane, died on July 11. The inquest in Leamington this month heard that many of the nurses on Oken ward were agency workers because of staff shortages. It was also said that nursing staff failed to alert doctors that Mr Game’s blood contained high levels of the waste material urea. The high level of urea was a sign that he was dehydrating or that his kidneys were failing. In recording a narrative verdict, Coroner Sean McGovern said: “I am satisfied that neglect caused and/or contributed to Mr Game’s death. “His developing acute renal failure was not recognised or if it was, it was not acted upon appropriately until his condition was such that he required admission to the ITU.” In his verdict the coroner said inadequately completed notes, management failure within the ward to monitor the systemic failures by nursing staff to document Mr Game’s condition and the fact that senior staff did not check his condition sooner contributed to his death. Mr Game was a former naval petty officer and toolmaker and had five grandchildren and seven great-grandchildren. Mr Game’s daughter, Pat Evans, said: “It’s so sad because dad always made sure he drank plenty of water. “At home he kept a bottle by his chair and in his car. “Yet he was allowed to dehydrate in hospital – the one place where everyone was supposed to be looking after him. It’s appalling.” A hospital spokeswoman said: “We wish to extend our condolences to the family for their loss and apologise unreservedly for the shortcomings in the care. “There has been no individual disciplinary action because it was not down to an individual – it was a system failure.” After a hospital investigation a number of changes were made, including appointing a senior nurse manager “to support the leadership” on the orthopaedic wards. Patients are now reviewed daily and any orthopaedic patients who are at risk or known to have a renal problem are identified to ensure appropriate monitoring.