Woman died after warning signs missed
00:00, 22 July 2005
updated: 10:31, 22 July 2005
STAFF at a private hospital failed to act on warning signs that could have saved a woman’s life.
Eledwen Demain, 67, of Yeoman Lane, Bearsted, died at Maidstone Hospital on March 24, last year, after developing a chest infection.
She had been in a coma for seven weeks following a rare complication from an epidural given to ease the pain of a routine spinal operation at the Somerfield Hospital in London Road, Maidstone.
An excess amount of anaesthesia led to complete respitatory collapse from which she never recovered.
An inquest held at County Hall, Maidstone, heard the problem could have been reversed had the symptoms - including low blood pressure, difficulty in swallowing and partial paralysis been picked up earlier and hospital protocols followed.
Mrs Demain had left the operating theatre at about 12.20pm. Her blood pressure lowered by anaesthetic drugs during the operation was expected to recover within an hour. An epidural catheter was fitted to give extra pain relief.
Consultant anaethetist Dr Sushama Day told the inquest how she expected Mrs Demain’s blood pressure to rise to 100 by 1.30pm an hour after coming out of theatre.
But she failed to communicate that to ward staff assuming they would contact her if blood pressure readings failed to improve. It was one of several communication failures between key staff members throughout the day.
In a written report following the hearing Mid Kent and Medway coronor Roger Sykes there had been significant warning signs that Mrs Demain’s health was in jeapordy in the hours following the operation.
There was also evidence that nursing staff - including the nurse in charge of the ward - had failed to comply with the hospital’s policy for the management of epidural anaethesia.
The nurse looking after the patient was not trained sufficiently to realise what was happening.
Had the warning signs and protocol been followed and appropriately acted upon the situation would have been "readily reversible".
Recording a narrative verdict the coronor said Mrs Demain had died from the consequences of sustained hypotension during the administration of an epidural anaethetic.
A spokeswoman for the Somerfield Hospital said that it had improved training for staff and updated policies as a result of the tragic incident.
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