‘Gross failures’ led to grandmother’s death

Margaret Churcher

Margaret Churcher - Credit: supplied

A NAILSEA grandmother died in hospital after nurses forgot to give her a crucial drug on at least three occasions.

Margaret Churcher suffered a severe stroke on May 27 last year and was admitted to Bristol Royal Infirmary. Just 18 days later she died after developing deep vein thrombosis (DVT).

During an inquest into her death at Flax Bourton Coroners Court on March 5, it was revealed a catalogue of errors contributed to Mrs Churcher’s demise.

Following her stroke, the 59-year-old of Woodland Road suffered a number of effects, including temporary loss of movement in her right arm and leg.

On June 5, stroke physician Dr Peter Murphy wrote a prescription for Clexane as he felt Mrs Churcher was at risk of developing DVT. A 40mg dose will reduce that risk by 50 per cent.


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However, doses were not administered on June 5, 6 and 9.

Nurses Marline Ahkon and Kathryn Heyhoe told the inquest they thought the prescription was unusual and decided to check it with a doctor. Both became distracted and forgot.

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Another nurse, Charlotte Roberts, also questioned the prescription and could not remember whether she later administered it.

A fourth nurse, Kathleen Tadawan, said she administered the Clexane on June 10 but forgot to record it.

Over the weekend of June 9-10, Mrs Churcher’s family told nurses her right leg was swollen but this was only reported to Dr Susan Tetlow on June 11 when she examined the leg and a later scan confirmed DVT.

Despite an increased dose of Clexane, on June 14 Mrs Churcher suffered a pulmonary embolism, a clot in the pulmonary artery which transports blood to the lungs, caused by the DVT in her leg, and died.

Dr Murphy, who triggered an internal investigation following Mrs Churcher’s death, said: “She had potentially missed four doses.

“If the family reported the swelling to a nurse, the nurse should then have reported it to a senior nurse and so on.”

Recording a verdict of natural causes contributed to by neglect, Coroner Maria Voisin said she considered the mistakes as a ‘gross failure’ which led to or contributed to Mrs Churcher’s death.

Described as an ‘amazing mum and nan’ by her daughters Louise and Debra, Mrs Churcher died two days before her and husband Ray’s 30th wedding anniversary.

Representing the Churcher family, who are now considering legal action against the BRI, Madeleine Pinschof of Thompsons solicitors said: “The family of Margaret Churcher, though devastated at their loss, are relieved the inquest confirmed what they knew was the case - their beloved wife, mother and grandmother died as a result of levels of care that fell well below what she and they had the right to expect.

“Margaret’s family are determined no other elderly, sick and vulnerable patient should be neglected as Margaret was and the hospital learns from the mistakes made in her care.”

Following the inquest, chief nurse for University Hospitals Bristol NHS Foundation Trust Alison Moon said: “It is essential we change practice when things go wrong and, since Mrs Churcher was a patient at the BRI, we have made significant changes.

“These include improving written and verbal communications between groups of staff and introducing teaching sessions, routine checks on patients for symptoms of DVT and improvements to the prescription chart.”

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